Association between Levels of Physical Activity, Sarcopenia, Type 2 Diabetes and the Quality of Life of Elderly People in Community Dwellings in Lebanon

Round 1

Reviewer 1 Report

The manuscript by Dana Saadeddine et al, entitled “Association Between Levels of Physical Activity, Sarcopenia, Type 2 Diabetes and the Quality of Life of Elderly People in  Community Dwellings in Lebanon” has been reviewed.

The authors aimed to examine the association between  the level of PA and sarcopenia, cardiovascular risk factors (i.e. dyslipidemia, Type 2 Diabetes (T2D) and cardiovascular diseases) and the health-related quality of life (HRQoL) among elderly people,  in community dwellings in Lebanon.

 

The topis is of interest, nevertheless the manuscript contain several flaws that deserve attention.

Abstract

1. In the line 21 “regression analysis showed that an increased rate of PA to ≥ 600 MET-min/week decreased the risk of T2D”  please replace the verb “decreased” with “it was associated with”; in order to avoid a causal misunderstanding.
2. Same for line 23 with the verb “improved”, replace with “it was associated with higher scores”

Methods

1. Authors stated that “linear regression models were used to determine the odds ratio of sarcopenia and cardio metabolic risk” (line 124). But they have not defined what is “cardiometabolic risk”
2. In the lines 126-127 authors stated “Models were adjusted for potential confounders (i.e., age, gender, having obesity or sarcopenia or not), considering a p value <0.25 in the univariate model.”  What do authors meand by considering a “p value <0.25 in the univariate model” do they used 0.25 as statistical threshold? Please provide any reference for such a decision
3. In the same lines they mentioned that the analysis were adjusted for obesity; why adjusting for obesity when such variable is itself part of the cardiometabolic risk ?
4. What was the statistical software employed?
5. Please clearly describe the model used
6. Please clearly describe the independent and dependent variable for each analysis

Results

1.  Please provide standardized beta coefficients
2. Please provide supplementary results for the analysis of MET-min/week without dichotomizing it.
3. Tables 2,3,4 & 5. It is not clear what the OR and betas represents, are those the results calculated for those subgroups (obesity, males, etc) if so, please consider another strategy, as the sample size and therefore the power is reduced drastically. Or are those the OR and betas resulting from the adjustment?  Then please notice that sex is a major contributor, possible more than the independent variable.

Discussion

1.  Please low the tone in the potential clinical implications, given the observational nature, and small sample size of the study.

Author Response

Reviewer 1

The manuscript by Dana Saadeddine et al, entitled “Association Between Levels of Physical Activity, Sarcopenia, Type 2 Diabetes and the Quality of Life of Elderly People in Community Dwellings in Lebanon” has been reviewed. The authors aimed to examine the association between the level of PA and sarcopenia, cardiovascular risk factors (i.e. dyslipidemia, Type 2 Diabetes (T2D) and cardiovascular diseases) and the health-related quality of life (HRQoL) among elderly people, in community dwellings in Lebanon. The topic is of interest, nevertheless the manuscript contain several flaws that deserve attention.

Abstract

In the line 21 “regression analysis showed that an increased rate of PA to ≥ 600 MET-min/week decreased the risk of T2D” please replace the verb “decreased” with “it was associated with”; in order to avoid a causal misunderstanding.

Response: Done as suggested (abstract, page 1). Moreover we specified the nature of study and underlined the need for future longitudinal investigations to clarify if intervention based on increasing levels of PA can determine improvement in these clinical outcomes (abstract, page 1).

Same for line 23 with the verb “improved”, replace with “it was associated with higher scores”

Response: Done as suggested (abstract, page 1). Moreover we specified the nature of study and underlined the need for future longitudinal investigations to clarify if intervention based on increasing levels of PA can determine improvement in these clinical outcomes (abstract, page 1).

Methods

Authors stated that “linear regression models were used to determine the odds ratio of sarcopenia and cardio metabolic risk” (line 124). But they have not defined what is “cardiometabolic risk”

Response: There was a typos mistake (Page 3, paragraph 5). Now we have meant cardiovascular risk factors that have been defined previously (Page 3, paragraph 4).

In the lines 126-127 authors stated “Models were adjusted for potential confounders (i.e., age, gender, having obesity or sarcopenia or not), considering a p value <0.25 in the univariate model.” What do authors meant by considering a “p value <0.25 in the univariate model” do they used 0.25 as statistical threshold? Please provide any reference for such a decision.

Response: The decision to select variable to be included in the regression models was based on the study by Bursac et al, 2008 (cited below). The citation has been added in the text and list of references (Page 3, paragraph 5 and Page 10, reference 25).

Bursac Z., et al. Purposeful selection of variables in logistic regression. Source Code Biol Med 3, 17 (2008). https://doi.org/10.1186/1751-0473-3-17.

In the same lines they mentioned that the analysis were adjusted for obesity; why adjusting for obesity when such variable is itself part of the cardiometabolic risk?

Response: we agree with the comment of the reviewer. However obesity is associated with higher risk of sarcopenia, type 2 diabetes and impairment of HRQoL. Therefore we adjust for it considering it as potential confounder.

What was the statistical software employed?

Response: Done as suggested (Page 3, paragraph 5).

Please clearly describe the model used

Response: Done as suggested (Page 3, paragraph 5 and tables 2, 3, 4 and 5).

Please clearly describe the independent and dependent variable for each analysis

Response: Done as suggested (Page 3, paragraph 5 and tables 2, 3, 4 and 5).

Results

Please provide standardized beta coefficients

Response: Done as suggested (Tables 4 and 5).

Please provide supplementary results for the analysis of MET-min/week without dichotomizing it.

Response: The analysis was repeated as per the request of the reviewer to include physical activity level in the univariate and multivariate models as a continuous variable in terms of Met-min/week instead of dichotomizing the variable (Supplementary file), and results were similar to those we obtained through dichotomizing. However we did not include them in the manuscript to avoid redundancy.

Tables 2, 3, 4 & 5. It is not clear what the OR and betas represents, are those the results calculated for those subgroups (obesity, males, etc.) if so, please consider another strategy, as the sample size and therefore the power is reduced drastically. Or are those the OR and betas resulting from the adjustment? Then please notice that sex is a major contributor, possible more than the independent variable.

Response: In tables 2 and 3 the odds for the univariate model represents the odds of the outcome using only one independent variable in the model and not a subgroup. The multivariate model on the other hand represent the odds after adjustment. Hence, the whole sample (n=243) was used in the regression analysis and the analysis is powered.

As for sex in tables 2 and 3 the Odds did not have statistical significance as illustrated by the 95% CI that incudes the value (1).

Considering tables 4 and 5, also the univariate model represents the Beta coefficient for the variable entered separately in the model and not the subgroups.

As for sex in tables 4 and 5, although mental or physical health quality of life would increase with male sex, still reduced physical activity was the main significant contributor to a reduction in the total Mental or Physical quality of life score predicted by the model among those with lower total Met-min/week.

Discussion

Please low the tone in the potential clinical implications, given the observational nature, and small sample size of the study.

Response: Done as suggested (Page 8, paragraph 4).

Author Response File: Author Response.pdf

Reviewer 2 Report

Thank you for the effort put into revising the manuscript and taking into account the comments of the Reviewer(s). In my opinion, your paper is more clear and the methodology section is now improved. Nevertheless, there are some elements that still need improvement. All comments are listed below:

• Line 69: Please add the word “severe” before cognitive impairment to match the examples given in the parentheses (i.e., dementia, Alzheimer's disease).
• Line 181: Please add some more references as you refer to “studies” and “populations”
• Lines 182-190: I would suggest to compare your results with other populations (not Arabic) as well, concerning their PA level.
• Lines 214-215: Correctly it is mentioned here that due to the cross-sectional design, no causal associations could be inferred between levels of PA and clinical outcomes. Therefore, I would suggest to re-read the whole manuscript and the abstract and check if there are expressions that imply that the found correlations establish causation.
• Please add the abbreviation of β also in table 5
• Please be consistent whether use “Met-min/week: or “Met-min per week” or “MET-minutes/week” or “MET-min/week”
  
  

Author Response

Reviewer 2

Thank you for the effort put into revising the manuscript and taking into account the comments of the Reviewer(s). In my opinion, your paper is more clear and the methodology section is now improved. Nevertheless, there are some elements that still need improvement. All comments are listed below:

Line 69: Please add the word “severe” before cognitive impairment to match the examples given in the parentheses (i.e., dementia, Alzheimer's disease).

Response: Done as suggested (Page 2, paragraph 4).

Line 181: Please add some more references as you refer to “studies” and “populations”

Response: We substitute the reference with a systematic review that include several studies and populations (Reference [29]).

Lines 182-190: I would suggest to compare your results with other populations (not Arabic) as well, concerning their PA level.

Response: Done as suggested (Page 8, paragraph 3).

Lines 214-215: Correctly it is mentioned here that due to the cross-sectional design, no causal associations could be inferred between levels of PA and clinical outcomes. Therefore, I would suggest to re-read the whole manuscript and the abstract and check if there are expressions that imply that the found correlations establish causation.

Response: Done as suggested.

Please add the abbreviation of β also in table 5

Response: Done as suggested (Table 5).

Please be consistent whether use “Met-min/week: or “Met-min per week” or “MET-minutes/week” or “MET-min/week”

Response: We revised the manuscript accordingly and now we are consistent with the use of MET-min/week.

Round 2

Reviewer 1 Report

The revised version of the manuscript by Dana Saadeddine et al, entitled “Association Between Levels of Physical Activity, Sarcopenia, Type 2 Diabetes and the Quality of Life of Elderly People in Community Dwellings in Lebanon” has been reviewed.

This reviewer thanks the authors for their work. I have only one remaining comment is to replace the term "gender" with "sex". It is my assumption that the authors recorded sex, but not gender.

 

Author Response

The revised version of the manuscript by Dana Saadeddine et al, entitled “Association Between Levels of Physical Activity, Sarcopenia, Type 2 Diabetes and the Quality of Life of Elderly People in Community Dwellings in Lebanon” has been reviewed. This reviewer thanks the authors for their work. I have only one remaining comment is to replace the term "gender" with "sex". It is my assumption that the authors recorded sex, but not gender.

Response: Done as suggested. We replaced the term "gender" with "sex".

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

The manuscript by Dana Saadeddine and colleagues, entitled “Association Between Levels of Physical Activity, Sarcopenia, Cardiovascular Risk Factors and the Quality of Life of Elderly  People in Community Dwellings in Lebanon” has been reviewed.

The aim of the manuscript was to evaluate the associations between physical activity, sarcopenia, cardiovascular risk factors and the quality of life of elderly people in community dwellings in Lebanon.

The research topic is of importance, but in general, the manuscript is not carefully written, and there are several parts that are difficult to understand. The manuscript should be improved in several aspects.

This reviewer has some suggestions.

Abstract.

1. 1. Authors did not include any result in the abstract. Please include the relevant results, by providing the numeric outcome, CI and p-values, if suitable. Please notice that sentences such as: “x is associated with y” are not enough.

 

Introduction

1. 2. The whole section lacks of important references. Please provide a background, or what is already know in the field.

Methods.

1. 3. Statistical sections seems to be inappropriately reported. For instance it seems that the Chi squared test was used for other means that what it is actually designed for.
2. 4. The sentcnce “Models were adjusted for potential confounders, considering a p value <0.25 in the simple model.” Is not clear. Please clarify what simple model and please provide a reference for such a procedure.
3. 5. The sentence “All tests were considered significantly different at p<0.05.” should be rephrased, since authors are looking for differences in the groups, not in the tests.
4. 6. Please replace the term gender by sex, as it is the assumption of this reviewer that authors retrieve the information about sex from the participants, not gender.

 

 

Results and Discussion

1. 7. Please provide the meaning of P, p and X2.
2. 8. Please provide the meaning of simple model and multiple model. Does the author mean univariable and multivariable?
3. 9. Please be clear in the results section, are the author reporting odd ratio? Or what kind of odds?
4. 10. What does B mean (table 5). Please describe if that represents un-standarized or standardized beta regression coefficient.
5. 11. Discussion section lacks the discussion of the results under the light of the already reported evidence.

Author Response

Reviewer # 1

The manuscript by Dana Saadeddine and colleagues, entitled “Association Between Levels of Physical Activity, Sarcopenia, Cardiovascular Risk Factors and the Quality of Life of Elderly People in Community Dwellings in Lebanon” has been reviewed. The aim of the manuscript was to evaluate the associations between physical activity, sarcopenia, cardiovascular risk factors and the quality of life of elderly people in community dwellings in Lebanon. The research topic is of importance, but in general, the manuscript is not carefully written, and there are several parts that are difficult to understand. The manuscript should be improved in several aspects. This reviewer has some suggestions.

Abstract

Authors did not include any result in the abstract. Please include the relevant results, by providing the numeric outcome, CI and p-values, if suitable. Please notice that sentences such as: “x is associated with y” are not enough.

Response: The abstract has been re-written including results and providing the numeric outcomes, as suggested (Page 1, abstract).

Introduction

The whole section lacks of important references. Please provide a background, or what is already know in the field.

Response: Now we added a paragraph that provides a background, to what is already know in the field especially in our region (Page 2, paragraph 2 and 3) and added relevant reference [8,9,10,11,12]:

• Sharara E, Akik C, Ghattas H, Makhlouf Obermeyer C: Physical inactivity, gender and culture in Arab countries: a systematic assessment of the literature. BMC Public Health. 2018 18;18(1):639.
• Al Senany S, Al Saif A. Assessment of physical health status and quality of life among Saudi older adults. J Phys Ther Sci. 2015;27(6):1691-5.
• Kamel MH, Abdulmajeed AA, Ismail Sel S. Risk factors of falls among elderly living in urban Suez–Egypt. Pan Afr Med J. 2013;14:26.
• Elshahat S, O'Rorke M, Adlakha D: Built environment correlates of physical activity in low- and middle-income countries: A systematic review. . PLoS One 2020, 15(3):e0230454.
• Chaabane S, Chaabna K, Abraham A, Mamtani R, Cheema S: Physical activity and sedentary behaviour in the Middle East and North Africa: An overview of systematic reviews and meta-analysis. Sci Rep. 2020;10(1):9363.

Methods.

Statistical section seems to be inappropriately reported. For instance it seems that the Chi squared test was used for other means that what it is actually designed for.

Response: the proper use of Chi squared test is indicated in the statistical analysis section (Page 3, paragraph 5).

 

The sentence “Models were adjusted for potential confounders, considering a p value <0.25 in the simple model.” Is not clear. Please clarify what simple model and please provide a reference for such a procedure.

Response: a simple model was used to indicate the univariate model using only one variable in the model. The description was modified accordingly in the statistical analysis section (Page 3, paragraph 5).

 

The sentence “All tests were considered significantly different at p<0.05.” should be rephrased, since authors are looking for differences in the groups, not in the tests.

Response: The statement was changed to “statistical significance for all tests was considered at p<0.05 (Page 3, paragraph 5).

 

Please replace the term gender by sex, as it is the assumption of this reviewer that authors retrieve the information about sex from the participants, not gender.

Response: the term gender has been replaced by sex as suggested.

 

Results and Discussion

Please provide the meaning of P, p and X2.

Response: provided the meaning as requested (Table 1).

 

Please provide the meaning of simple model and multiple model. Does the author mean univariable and multivariable?

Response: Changed in the statistical analysis section to indicate that simple and multiple models indicate univariate and multivariate models respectively (Page 3, paragraph 5).

 

Please be clear in the results section, are the author reporting odd ratio? Or what kind of odds?

Response: Done as suggested. Now to it is read as odd ratio (Page 4, paragraph 2).

 

What does B mean (table 5). Please describe if that represents un-standarized or standardized beta regression coefficient.

Response: B represents the unstandardized regression coefficient Beta (Table 5).   

 

Discussion section lacks the discussion of the results under the light of the already reported evidence.

Response: All results are now better described in the Discussion section under the light of the already reported evidence (Page 8, paragraph 5).

 

 

Author Response File: Author Response.pdf

Reviewer 2 Report

The aim of the present study was to examine the association between the level of physical activity and sarcopenia, cardiovascular risk factors and the quality of life among elderly people in community dwellings in Lebanon. I believe that presenting data from low- and middle-income countries is important and worth publishing. However, I have some major considerations regarding the present study, mainly on methodological issues.

 

ABSTRACT

• Line 24: I suggest removing “if confirmed” (also mentioned in the Discussion section), as using it implies questioning the results of the present study

 

INTRODUCTION

• Lines 43-44: The rationale about the positive effects of PA on clinical outcomes in low- and middle-income countries is not justified and introduced appropriately. As the benefits of PA are well-established, what the authors expected to be different in these countries?
• Lines 45-48: The recommendations in the new guidelines refer only to min/week. Therefore, could the authors please explain the cut-off point of 500 MET-minutes a week that was used in the study?

 

METHODS

• Lines 60-61: How this exclusion criterion (“having the ability to follow instructions regarding how to fill out the questionnaires”) was established? In addition, as cognitive impairment / dementia is one of the main diseases in the elderly, shouldn’t be an exclusion criterion?
• Lines 66-68: Please re-write the sentence to be clearer for the reader, i.e. did the study involved a control group; what “test” refers to?
• Line 71: Please add the BMI equation
• Lines 72-82: This paragraph does not need to be separated from the previous paragraph. Why body weight was not measured with the body composition analyzer? Body weight was measured the same day as body composition? Moreover, the body composition measurements were taken following overnight fast, or hours following caffeine/water consumption?
• Lines 80-82: The reference of Oh et al. for sarcopenia refers to Korean individuals. Even though this reference has been previously used in Lebanese population, I suggest using the revised criteria of sarcopenia recently published by Cruz-Jentoft (Age and Ageing 2019; 48: 16–31; Sarcopenia: Revised European consensus on definition and diagnosis).
• Lines 69-82 & 101-105: The body composition and cardiovascular risk description is almost identical to a previous paper from the authors (Kreidieh D, Itani L, El Masri D, Tannir H, El Ghoch M: Association Between Reduced Daily Steps and Sarcopenic Obesity 303 in Treatment-Seeking Adults With Obesity. Front Endocrinol (Lausanne) 2020, 30(11):22.)
• Is this study a part of a larger study, or other parts of this study have already been published?
• Line 86: What is “one single item scale on health transition”?
• Lines 93-100: Please explain how the IPAQ score was calculated as MET-min per week
• Line 111: Which were the potential confounders?

 

RESULTS

• Table 1: Please superscript “2” in x² and in Kg/m²
• Table 1: What was the criterion for obesity?
• Table 1: As I can understand Table 1 shows only number of participants for each variable (except SF-36). However, it is important to see also the data for other variables such as PA, obesity and sarcopenia.
• Table 6: Please replace “emotional” with “mental”

 

DISCUSSION

• Line 216: Please replace “research” with “reach”
• Line 228: The impedance analyzer used in this study was multi- or single-frequency as described in line 75? Furthermore, the abbreviation of BIA was not previously explained.
• Lines 221-222: Using IPAQ should not be considered as a strength in this study as it was not the most suitable for the population studied (elderly). There are physical activity questionnaires specifically designed for the elderly (e.g., PASE, PASB-Q).
• Generally, the discussion section must be considerably improved. In addition, I would suggest writing smaller sentences to be clearer for the reader.

 

Author Response

Reviewer # 2

The aim of the present study was to examine the association between the level of physical activity and sarcopenia, cardiovascular risk factors and the quality of life among elderly people in community dwellings in Lebanon. I believe that presenting data from low- and middle-income countries is important and worth publishing. However, I have some major considerations regarding the present study, mainly on methodological issues.

ABSTRACT

• Line 24:I suggest removing “if confirmed” (also mentioned in the Discussion section), as using it implies questioning the results of the present study

Response: We removed “if confirmed” as suggested (Page 1, abstract).

INTRODUCTION

1. Lines 43-44: The rationale about the positive effects of PA on clinical outcomes in low- and middle-income countries is not justified and introduced appropriately. As the benefits of PA are well established, what the authors expected to be different in these countries?

Response: Now we added a paragraph that provides the rational behind our study, (Page 2, paragraph 2 and 3) and added relevant reference [8,9,10,11,12]:

• Sharara E, Akik C, Ghattas H, Makhlouf Obermeyer C: Physical inactivity, gender and culture in Arab countries: a systematic assessment of the literature. BMC Public Health. 2018 18;18(1):639.
• Al Senany S, Al Saif A. Assessment of physical health status and quality of life among Saudi older adults. J Phys Ther Sci. 2015;27(6):1691-5.
• Kamel MH, Abdulmajeed AA, Ismail Sel S. Risk factors of falls among elderly living in urban Suez–Egypt. Pan Afr Med J. 2013;14:26.
• Elshahat S, O'Rorke M, Adlakha D: Built environment correlates of physical activity in low- and middle-income countries: A systematic review. . PLoS One 2020, 15(3):e0230454.
• Chaabane S, Chaabna K, Abraham A, Mamtani R, Cheema S: Physical activity and sedentary behaviour in the Middle East and North Africa: An overview of systematic reviews and meta-analysis. Sci Rep. 2020;10(1):9363.

 

• Lines 45-48:The recommendations in the new guidelines refer only to min/week. Therefore, could the authors please explain the cut-off point of 500 MET-minutes a week that was used in the study?

Response: We explained this point in the Introduction section (Page 2, paragraph 1).

METHODS

• Lines 60-61:How this exclusion criterion (“having the ability to follow instructions regarding how to fill out the questionnaires”) was established? In addition, as cognitive impairment / dementia is one of the main diseases in the elderly, shouldn’t be an exclusion criterion?

Response: We now clarify that the statement as: having the ability to read and write in order to follow instructions regarding how to fill out the questionnaires. Moreover we added also cognitive the impairment (i.e. dementia, Alzheimer's disease) among exclusion criteria (Page 2, paragraph 4).

 

• Lines 66-68:Please re-write the sentence to be clearer for the reader, i.e. did the study involved a control group; what “test” refers to?

Response: The sentence to be clearer to the readers as suggested (Page 2, paragraph 5).

 

• Line 71: Please add the BMI equation

Response: Done as suggested (Page 2, paragraph 6).

 

• Lines 72-82: This paragraph does not need to be separated from the previous paragraph. Why body weight was not measured with the body composition analyzer? Body weight was measured the same day as body composition? Moreover, the body composition measurements were taken following overnight fast, or hours following caffeine/water consumption?

Response: Body weight and body composition were measured separately but in the same occasion on the morning. All recommendations for a correct body weight and bioimpedance (BIA) measurements were followed, and now clearly mentioned in the Method section (Page 2, paragraph 6 and 7; page 3, paragraph 1).

 

• Lines 80-82: The reference of Oh et al. for sarcopenia refers to Korean individuals. Even though this reference has been previously used in Lebanese population, I suggest using the revised criteria of sarcopenia recently published by Cruz-Jentoft (Age and Ageing 2019; 48: 16–31; Sarcopenia: Revised European consensus on definition and diagnosis).

Response: We thank the reviewer for his/her suggestion Oh definition was established to define Sarcopenic Obesity, which suits our population since it is mainly composed of individuals with overweight and obesity. Moreover, this definition has been used several studies have used this definition and tested its clinical usefulness. We hope that the reviewer understand our point of view.

 

• Lines 69-82 & 101-105:The body composition and cardiovascular risk description is almost identical to a previous paper from the authors (Kreidieh D, Itani L, El Masri D, Tannir H, El Ghoch M: Association Between Reduced Daily Steps and Sarcopenic Obesity 303 in Treatment-Seeking Adults With Obesity. Front Endocrinol (Lausanne) 2020, 30(11): 22.). Is this study a part of a larger study, or other parts of this study have already been published?

Response: The two samples are completely different, with no overlapping. In fact the sample in the above mentioned study is composed of seeking-treatment patient with obesity, referral by general practitioners to the Nutritional and Weight Management Outpatient Clinic in the Department of Nutrition and Dietetics at Beirut Arab University (BAU) in Lebanon during the period May 2017 to July 2019. The eligibility criteria were mainly: age ≥ 18 years, with a BMI ≥ 30.0 kg/m², and the mean age in the indicated study was 37.12±15.58 years. On the other hand the sample in the currents are in elderly people (age ≥ 60 years) in community dwellings, with the mean age of 67.87±6.64 years.

 

• Line 86:What is “one single item scale on health transition”?

Response: The statement has been rephrased to read as: one single item scale on changes in health over the last 12 months (Page 3, paragraph 2).

 

• Lines 93-100:Please explain how the IPAQ score was calculated as MET-min per week

Response: We explained now how the IPAQ score was calculated as MET-min per week as suggested (Page 3, paragraph 3).

 

• Line 111:Which were the potential confounders?

Response: Added the potential confounders (Page 3, paragraph 5).

RESULTS

• Table 1:Please superscript “2” in x² and in Kg/m²

Response: Done as suggested (Table 1).

• Table 1:What was the criterion for obesity?

Response: Now has been clarified (Table 1).

• Table 1:As I can understand Table 1 shows only number of participants for each variable (except SF-36).

Response: age and SF-36 are presented as means (SD) since are continuous variables, the other variables are presented as n (%) since are categorical variables. This has been specified in the caption of Table 1.

 

• However, it is important to see also the data for other variables such as PA, obesity and Response:

Done as suggested in Table 1.

 

• Table 6:Please replace “emotional” with “mental”

Response: Done as suggested (Table 6).

 

DISCUSSION

• Line 216:Please replace “research” with “reach”

Response: Done as suggested (Page 8, paragraph 6).

 

• Line 228:The impedance analyzer used in this study was multi- or single-frequency as described in line 75? Furthermore, the abbreviation of BIA was not previously explained.

Response: The description of the body composition analyser has been re-written properly to appear clear (Page 2, paragraph 7).

 

• Lines 221-222:Using IPAQ should not be considered as strength in this study as it was not the most suitable for the population studied (elderly). There are physical activity questionnaires specifically designed for the elderly (e.g., PASE, PASB-Q).

Response: As suggested we remove that the use of IPAQ is a strength, and added it within the limitations (Page 9, paragraph 2).

 

• Generally, the discussion section must be considerably improved. In addition, I would suggest writing smaller sentences to be clearer for the reader.

Response: All in all, the Discussion section has been improved in form and content as suggested.

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

The authors presented a revised version of the work. Although the paper has been improved, I have still important concerns that prevent me from accepting this work.

Lines 45-48: There is still no answer to the question “The recommendations in the new guidelines refer only to min/week. Therefore, could the authors please explain the cut-off point of 500 MET-minutes a week that was used in the study?” If I understood well, did the authors convert the min/wk guidelines to MET? Because in the cited reference (Bull et al., 2020) the cut-off in MET values that was used in the study does not exist. Moderate intensity equals to 4 MET according to IPAQ, or 3-6 MET according to the cited paper. Therefore, I cannot figure out how 150min/wk were converted to 500MET. This is very important as analysis of the results was based on this cut-off.

Line 53: Please explain the MENA abbreviation

Line 97: Even though the authors rephrased the “one single item scale”, I still do not understand what does it refer to. Furthermore, the two components are calculated based on the eight scales, therefore, how the result of this item scale is interpreted?

Table 1: The average MET for the total population is very large.