Relationship of Nutritional Status and Physical Activity Level with Dynamic Postural Balance in Young Adults

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for submitting your manuscript. Please see my comments and suggestions below:

Abstract. It appears that you present unstandardized regression coefficients in the abstract. Thus, I recommend replacing "β" with "B" or providing standardized coefficients instead.

Causal language. Given the cross-sectional nature of your data, please avoid causal terminology such as "determinants" (in the study title), "influence" (study aim, line 102; Statistical Analysis, line 173), etc. Please revise throughout the manuscript, replacing such terms with "associations."

Participant recruitment and sample characteristics. The recruitment procedure for participants should be more clearly detailed in section 2.1. Additionally, in section 2.2, please provide a more comprehensive description of the sample, specifically including details about health and socio-economic status. The current sample description limits the reader's ability to assess the generalizability of your findings. Have the authors conducted a formal sample size calculation? If so, please include this information.

Calculation and interpretation of body balance percentages. In section 2.5, clarify how the body balance percentages reported in Tables 2 and 3 were calculated and explicitly state their meaning.

Statistical Analysis (lines 178-179). It is currently unclear which variables were excluded from the regression models due to multicollinearity, particularly since only two or three independent predictors are mentioned. Please clarify this.

Tables and figures. Please define the abbreviations "PM" and "PL" in the footnotes of Table 2. Consider adding p-values to Tables 2 and 3 to indicate the statistical significance of body balance differences across PA and BMI groups. Figures 1 and 2 require a legend explaining the meaning of the color-coded columns.

Regression analysis. The earlier comment for the abstract regarding the usage of "β" and "B" also applies here. Please clarify whether regression coefficients are standardized or unstandardized throughout the manuscript. I recommend providing summary tables for the regression analysis, indicating both models and specifying the dependent variables. In lines 251 and 257, specify the factors that were adjusted for. Have you explored any potential moderating effects of sex on the associations between physical activity level, nutritional status, and body balance? If conducted, please include these analyses.

Discussion, lines 270 and 285. Please replace causal language such as "influencing factors" and "influence" with more appropriate non-causal terminology.

Thank you for addressing these comments.

Author Response

Comments 1:  It appears that you present unstandardized regression coefficients in the abstract. Thus, I recommend replacing "β" with "B" or providing standardized coefficients instead.

Response 1: modified as suggested.

 

Comments 2: Given the cross-sectional nature of your data, please avoid causal terminology such as "determinants" (in the study title), "influence" (study aim, line 102; Statistical Analysis, line 173), etc. Please revise throughout the manuscript, replacing such terms with "associations."

Response 2: modified as suggested.

 

Comments 3: The recruitment procedure for participants should be more clearly detailed in section 2.1. Additionally, in section 2.2, please provide a more comprehensive description of the sample, specifically including details about health and socio-economic status. The current sample description limits the reader's ability to assess the generalizability of your findings. Have the authors conducted a formal sample size calculation? If so, please include this information.

Response 3: The request is as follows:

2.1 Design

This descriptive, observational, and cross-sectional study was conducted in accordance with the STROBE guidelines [24] and approved by the Universidad Santo Tomás Research Ethics Board (approval number 7819). Participants were recruited through digital invitations distributed via institutional email lists, social media platforms, and classroom announcements in higher education institutions in the Maule region (Chile), including universities, professional institutes, and technical training centers. The recruitment strategy was non-probabilistic and based on convenience sampling. Interested individuals contacted the research team and were screened for eligibility. Written informed consent was obtained from all participants prior to data collection.

 

2.2 Participants

The sample size was calculated using GPower* software version 3.1 (Universität Düsseldorf, Germany). Based on prior research by Guzmán-Muñoz et al. (2023), which identified moderate associations between anthropometric and behavioral factors with postural balance in youth populations, a medium effect size (f² = 0.15) was assumed for a multiple linear regression with three predictors (nutritional status, physical activity level, and sex). Using an alpha level of 0.05 and a power of 0.95, the minimum sample size required was 119 participants. To increase statistical power and allow for subgroup analyses, a final sample of 189 participants was included.

A total of 81 females and 108 males aged 18 to 29 years voluntarily participated in the study. All were currently enrolled in undergraduate or technical education programs. Exclusion criteria included any musculoskeletal injury in the lower limbs within the previous six months, diagnosed vestibular or visual impairments, or the need for assistive devices for ambulation.

Regarding general health, participants self-reported the absence of chronic diseases or conditions that could affect postural control (e.g., neurological disorders, diabetes, recent surgeries). Although no formal medical screening was performed, participants were instructed to report any medical conditions that might compromise their safety or data validity. Socioeconomic status was not directly measured; however, the sample comprised students from public and private institutions with varied tuition costs and scholarship coverage, suggesting a heterogeneous socioeconomic background typical of the regional higher education context.

 

Comments 4: In section 2.5, clarify how the body balance percentages reported in Tables 2 and 3 were calculated and explicitly state their meaning.

Response 4: 

Is added:

Reach distances were normalized relative to lower limb length using the formula: (Reach distance [cm] / Limb length [cm]) × 100%. Limb length was measured from the anterior superior iliac spine to the medial malleolus [30,31]. A higher value in percentage rep-resents a better dynamic postural balance.

 

Comments 5: It is currently unclear which variables were excluded from the regression models due to multicollinearity, particularly since only two or three independent predictors are mentioned. Please clarify this.

Response 5:

is added:

Prior to performing multiple linear regression analyses, all independent variables were tested for multicollinearity using variance inflation factor (VIF) and tolerance statistics. The initial set of predictors included nutritional status (BMI categories), physical activity level (IPAQ-SF categories), sex and age. However, age was excluded from the final models due to high collinearity with BMI (VIF > 10.0 and tolerance < 0.10), which could compromise model stability. The final regression models therefore included three predictors: nutritional status, physical activity level, and sex. These variables demonstrated acceptable collinearity diagnostics (VIF < 2.0), ensuring robust model estimation. The significance level for all tests was p < 0.05.

 

Comments 6: Please define the abbreviations "PM" and "PL" in the footnotes of Table 2. Consider adding p-values to Tables 2 and 3 to indicate the statistical significance of body balance differences across PA and BMI groups. Figures 1 and 2 require a legend explaining the meaning of the color-coded columns.

Response 6: The reviewer's suggestions are added, including p-values ​​in the tables.

 

Comments 7: The earlier comment for the abstract regarding the usage of "β" and "B" also applies here. Please clarify whether regression coefficients are standardized or unstandardized throughout the manuscript. I recommend providing summary tables for the regression analysis, indicating both models and specifying the dependent variables. In lines 251 and 257, specify the factors that were adjusted for. Have you explored any potential moderating effects of sex on the associations between physical activity level, nutritional status, and body balance? If conducted, please include these analyses.

Response 7: Thank you for your insightful suggestions. In response, we have replaced all instances of the symbol “β” with “B” to accurately reflect that all regression coefficients presented are unstandardized, as is appropriate given the categorical nature of our predictor variables. This clarification has been applied consistently throughout the manuscript, including the abstract, results, and new summary tables. In the Statistical Analysis section, we now explicitly describe the structure of the two regression models used: an unadjusted model including nutritional status and physical activity level, and an adjusted model that includes sex as a covariate.

 

Comments 8: Please replace causal language such as "influencing factors" and "influence" with more appropriate non-causal terminology.

Response 8: We have applied this adjustment to the entire new version of the manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

I sincerely thank the editor and the authors for the opportunity to review this interesting and well-structured manuscript, which addresses a relevant and timely topic such as the influence of nutritional status and physical activity level on dynamic postural balance in young adults. Among the strengths of the manuscript are the clarity of its objectives, the solid methodology, the use of validated tools such as the IPAQ-SF and SEBTm, and the use of multivariate statistical analysis, which allowed for control of confounding variables such as sex. The text is well-written and thoroughly documented from a bibliographic perspective. However, several revisions are necessary. Line 26: “The increasing prevalence…” — consider adding an updated reference, possibly including data from the 2023 World Obesity Atlas, already cited later. Line 35-36: the repetition of the same β coefficient for PAL and nutritional status suggests a potential editing or analysis error — please verify and correct. Line 97: it would be useful to indicate the study design of the cited Guzmán et al. (2023) to make the comparison stronger. Line 137-139: specify whether the IPAQ was administered in person or remotely, as this can influence data validity. Line 157: clarify whether the same dominant limb was used for all participants — was laterality verified? Line 186: consider adding the total mean BMI for the sample to enhance clarity. Line 207-208: this sentence could be rephrased for better clarity — for example: “no significant differences were observed between normal-weight and overweight participants.” Line 245-246: the identical β value to the previous line should be double-checked. Lines 313-319: although the limitations are present, they can be strengthened. Consider highlighting the lack of longitudinal data, the absence of objective physical activity measurements (e.g., accelerometers), and potential motivational bias during testing. Line 327: the idea of “screening” could be expanded to include educational and sports contexts. No section requires removal, as all contribute coherently to the rationale of the study. The data analysis is appropriate, with a relevant use of ANOVA, t-tests, and multiple regression. However, the inclusion of two models (with and without sex adjustment) could be supported by a more explicit theoretical rationale in the text. The authors are invited to include the following two key references, which offer relevant insights that align with the objectives of the current work:

1. Mancone, S., Corrado, S., Tosti, B., Spica, G., Di Siena, F., Misiti, F., & Diotaiuti, P. (2024). Enhancing nutritional knowledge and self-regulation among adolescents: efficacy of a multifaceted food literacy intervention. Frontiers in Psychology, 15, 1405414. https://doi.org/10.3389/fpsyg.2024.1405414

2. Diotaiuti, P., Girelli, L., Mancone, S., Valente, G., Bellizzi, F., Misiti, F., & Cavicchiolo, E. (2022). Psychometric properties and measurement invariance across gender of the Italian version of the Tempest Self-Regulation Questionnaire for Eating adapted for young adults. Frontiers in Psychology, 13, 941784. https://doi.org/10.3389/fpsyg.2022.941784

The first reference could be cited in the introduction (around line 71) to support the connection between nutritional behavior, nutritional knowledge, and postural balance in youth. The second reference could be included in the Discussion section (after line 284), reinforcing the role of behavioral self-regulation in postural and motor dynamics, particularly in relation to physical activity. Both references would add depth to the manuscript, especially by integrating a psychoeducational and preventive health perspective. The study is valuable and solid, but it could benefit from deeper elaboration of psychological factors involved in motor behavior

Comments on the Quality of English Language

The quality of the English language in the manuscript is generally high. The text is clearly written, well-structured, and easy to follow. Terminology is appropriate for the academic context, and the authors effectively communicate their findings and rationale. However, minor edits are recommended to improve precision and fluency, such as avoiding redundancy (e.g., identical β coefficients in multiple places) and rephrasing a few sentences for better clarity. Overall, the manuscript demonstrates a good command of academic English and requires only light language revision

Author Response

Comment 1 (Line 26): “The increasing prevalence…” — consider adding an updated reference, possibly including data from the 2023 World Obesity Atlas, already cited later.

Response 1: Thank you for the suggestion. We have updated the sentence to include recent data from the 2023 World Obesity Atlas, as recommended. The updated reference is now cited at the first mention of global obesity trends to provide timely and relevant context.

 

Comment 2 (Line 35–36): The repetition of the same β coefficient for PAL and nutritional status suggests a potential editing or analysis error — please verify and correct.

Response 2: We appreciate this observation. Upon rechecking the regression models, we confirmed that the repetition of identical β values was a result of a previous draft misstatement. The corrected coefficients now reflect the actual outputs of the regression analysis: for the adjusted model in the posteromedial direction, β = 2.784 (p = 0.015) for nutritional status, and β = 2.962 (p = 0.015) for physical activity level.

 

Comments 3 Line 137–139: Specify whether the IPAQ was administered in person or remotely, as this can influence data validity.

Response 3: Thank you for the comment. We have added this detail in the Methods section. The IPAQ-SF questionnaire was administered in person under the supervision of the research team, ensuring standardized instruction and minimizing misinterpretation, which supports data validity.

 

Comments 4 Line 157: Clarify whether the same dominant limb was used for all participants — was laterality verified?

Response 4: We appreciate this suggestion. We have clarified that laterality was verified for each participant through self-report of preferred kicking leg, and the SEBTm was performed on the dominant limb only for all individuals to ensure consistency across the sample.

 

Comments 5: Line 207–208: This sentence could be rephrased for better clarity.

Response 5: The sentence has been rephrased.

 

Comments 6: Line 245–246: The identical β value to the previous line should be double-checked.

Response 6: We have rechecked the regression output and corrected the values. The initial repetition was a drafting error. The corrected coefficients are now accurately presented.

 

Comments 7: Lines 313–319: Although the limitations are present, they can be strengthened.

Response 7: Thank you for this recommendation. We have expanded the limitations section to include:

• The cross-sectional nature of the study, which limits causal inferences.

• The use of self-reported physical activity (IPAQ-SF) instead of objective measures such as accelerometry.

• The potential for motivational bias during the physical performance assessments, especially in a testing environment.

 

comments 8: Line 327: The idea of “screening” could be expanded to include educational and sports contexts.

Response 8: We agree and have extended the statement to include:
“Dynamic balance screening could be implemented not only in clinical settings, but also in educational and sports environments to guide early interventions targeting physical function and injury prevention.”

 

Comments 9:  General comment on data analysis:
The inclusion of two models (with and without sex adjustment) could be supported by a more explicit theoretical rationale in the text.

Response 9: We appreciate this observation and have added a brief rationale in the Methods and Discussion sections, explaining that sex was included as an adjustment variable based on known physiological and neuromuscular differences in postural balance performance between males and females in young adult populations.

 

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review the paper on dietary status and physical activity level and their relationship to postural balance. This is an interesting paper. However, I also noted several areas that must be revised. Please find the detailed report below. 

Major comments:
- Point 2.3- specify the time of the day when you measured weight and height. Was it in the morning? Was it in the fasted state?
- Point 2.4—Add the PaLS Study on the university students to the validation studies of IPAQ on university students in line 129. See doi: 10.3390/ijerph18189632.
- Point 2.5- did you ensure a familiarization session for the balance test? How did the session? 
- Point. 2.5- which type of ICC was used in this validation study?
- Point 2.6- why you use Kolmogorov-Smirnov test. Which is appropriate for larger samples. For you the sample more appropriate is Shapiro-Wilk.
- Point 2.6- did you test the sample size? Exact calculations, for example from the G*Power, would be welcome.
- Table 1- The BMI of your participants was slightly increased and therefore, they were overweight. This. The issue should be discussed further. 
- ANOVA should be presented according to the AMA Manual of Style. Briefly, where are your F-statistics, degrees of freedom, etc?
- Similarly, regressions should follow the above-mentioned guidelines. Provide F-statistics, especially when p-values are not significant. 
- Specify the time and location of your study. Moreover, specify the number of potentially recruited participants and finally include. 
- Finally, you used the STROBE guidelines. Therefore, attach the checklist as a supplementary file. 

Minor comments:
- I think that you could add the BMI values to brackets with age in the abstract. See that your results strongly focus on BMI. However, the reader does not know from the abstract what the BMI is. 
- Abbreviations from figures should be explained in the footnotes. 
- Reconsider mentioning in the discussion that physical activity level and nutrition status deteriorated during the COVID-19 pandemic. This is an interesting implication for further analysis of your study results because those results could differ in different periods (eg. during the pandemic). Interesting papers that could be referenced here are doi: 10.3390/ijerph19148484 and doi: 10.3390/nu14245381.

To sum up my report, I recommend major revisions.

Author Response

Comments 1 Point 2.3: Specify the time of the day when you measured weight and height. Was it in the morning? Was it in the fasted state?
Response 1: Thank you for the suggestion. We have added the following detail in the Methods section (2.3): “All anthropometric measurements were taken in the morning hours (between 8:00 a.m. and 11:00 a.m.) with participants in a fasted state, wearing light clothing and no shoes.”

Comments 2 Point 2.4: Add the PaLS Study on the university students to the validation studies of IPAQ on university students in line 129.
Response 2: We appreciate this recommendation. The following reference has been included in line 129: “The validity of the IPAQ-SF in university populations has also been supported by recent studies such as the PaLS Study (doi: 10.3390/ijerph18189632).”

Comments 3: Point 2.5 (familiarization): Did you ensure a familiarization session for the balance test?
Response 3: Yes, we have clarified in the Methods (Section 2.5) that a brief familiarization session was conducted: “Before the SEBTm, participants completed a familiarization trial in each direction to minimize learning effects and ensure test reliability.”

 

Comments 4: Point 2.6 (normality test): Why did you use Kolmogorov-Smirnov? Shapiro-Wilk is more appropriate for small samples.
Response 4: We thank the reviewer for this observation. There was a mistake in the manuscript regarding the normality test used. In fact, we applied the Shapiro–Wilk test. The manuscript has been corrected accordingly to reflect the correct statistical procedure.

comments 5 Point 2.6 (sample size): Did you test the sample size? Exact calculations, for example from GPower, would be welcome.*
Response 5: We have now included an a priori sample size calculation.

 

Comments 6 Table 1 – BMI levels: The BMI of your participants was slightly increased. This should be discussed further.
Response 6: We agree with this important point. A brief comment has been added to the Discussion section highlighting that although the mean BMI falls within the overweight range, the variability across sex and PAL groups may influence postural balance performance and deserves further investigation.

 

Comments 7: Study time and location: Specify time and location of your study, number of potentially recruited participants, etc.
Response 7: We have added this information to the Methods section.

 

Comments 8 STROBE checklist: Attach the STROBE checklist as a supplementary file.
Response 8: The STROBE checklist has been completed and uploaded as a Supplementary File in accordance with journal requirements.

 

Comments 9:  Figure abbreviations:
Response 9: All abbreviations used in figures have been explained in the respective footnotes, as requested.

 

 

Reviewer 4 Report

Comments and Suggestions for Authors

I had the great privilege to review the manuscript entitled “Nutritional Status and Physical Activity Level as Determinants 2 of Dynamic Postural Balance in Young Adults” However, the manuscript can be improved by addressing the following points that the authors should consider:

1. The introduction presents the background and research aim clearly; however, it is overly lengthy and repetitive. The section redundantly emphasizes the epidemiology of obesity and physical inactivity (lines 47–61) without adequately narrowing the focus to the study’s central construct—dynamic postural balance. Mechanistic explanations (lines 62–72) are speculative and lack sufficient literature support. The research objective, although stated, appears too late and lacks logical flow from the preceding content. Furthermore, it is framed in vague terms ("influence"), without clearly defined hypotheses or expected directional relationships. Citations are heavily reliant on Chilean data and the authors’ prior work, limiting international relevance. Broader and more balanced references, including systematic reviews, are recommended.
2. Although the structure is clear in Materials and Method, several methodological concerns remain. The use of a convenience sample introduces potential selection bias, which is not addressed. Participant characteristics are underreported, limiting generalizability. BMI was the sole measure of nutritional status, without additional indicators (e.g., waist circumference, body fat), increasing the risk of misclassification. Physical activity assessment via IPAQ-SF may be affected by recall and social desirability biases, and its validity in this population is not discussed. The SEBTm lacks details on test environment, examiner training, and trial controls, potentially affecting reliability. Limb dominance determination is unclear. While statistical methods are generally appropriate, the binary classification of physical activity is overly simplistic, and key regression assumptions are not reported.
3. The Result section is logically organized but lacks essential statistical metrics (e.g., effect sizes, confidence intervals), reducing result interpretability. While sex-based subgroup analysis is included, the absence of interaction testing limits insights into moderating effects. Balance tests focus only on one limb and three directions, overlooking asymmetries and broader movement patterns. Figures lack confidence intervals and significance markers. The regression model includes only three predictors, omitting key confounders (e.g., sleep, exercise history, mental health), weakening its explanatory power.
4. The discussion reiterates findings without offering sufficient theoretical interpretation or cross-study comparisons. Explanations for sex differences in balance (e.g., muscle mass, physical activity habits) are reasonable but superficial; deeper physiological or neuroendocrine factors are not addressed. The rationale for the non-significant anterior direction is speculative and unsupported by literature. Study limitations are acknowledged but not critically examined—sampling bias, questionnaire limitations, and untested measurement assumptions are mentioned without sufficient elaboration. Furthermore, the potential clinical or public health implications of the findings are not discussed, nor is their relevance to broader populations beyond the specific demographic studied.
5. The authors assessed nutritional status solely using BMI, which is a limited approach that does not comprehensively reflect nutritional condition, such as body fat distribution, dietary intake, or metabolic indicators. Therefore, the term "Nutritional Status" in the title may be overly broad. It is recommended to revise the title for greater accuracy and alignment with the study content, for example: "Body Mass Index and Physical Activity Level as Determinants of Dynamic Postural Balance in Young Adults."

Author Response

Comments 1: 

The introduction presents the background and research aim clearly; however, it is overly lengthy and repetitive. The section redundantly emphasizes the epidemiology of obesity and physical inactivity (lines 47–61) without adequately narrowing the focus to the study’s central construct—dynamic postural balance. Mechanistic explanations (lines 62–72) are speculative and lack sufficient literature support. The research objective, although stated, appears too late and lacks logical flow from the preceding content. Furthermore, it is framed in vague terms ("influence"), without clearly defined hypotheses or expected directional relationships. Citations are heavily reliant on Chilean data and the authors’ prior work, limiting international relevance. Broader and more balanced references, including systematic reviews, are recommended.

Response 1: We appreciate this insightful and detailed feedback. In response, we revised the introduction to reduce length and eliminate repetitive content, particularly the overemphasis on epidemiological data. We refined the transition toward the study’s central construct—dynamic postural balance—and removed or supported speculative mechanistic explanations with appropriate references. The research objective has been reworded to more clearly reflect the study's analytical approach, specifying the variables and expected relationships. 


Comments 2: 

Although the structure is clear in Materials and Method, several methodological concerns remain. The use of a convenience sample introduces potential selection bias, which is not addressed. Participant characteristics are underreported, limiting generalizability. BMI was the sole measure of nutritional status, without additional indicators (e.g., waist circumference, body fat), increasing the risk of misclassification. Physical activity assessment via IPAQ-SF may be affected by recall and social desirability biases, and its validity in this population is not discussed. The SEBTm lacks details on test environment, examiner training, and trial controls, potentially affecting reliability. Limb dominance determination is unclear. While statistical methods are generally appropriate, the binary classification of physical activity is overly simplistic, and key regression assumptions are not reported.

Response 2: Thank you for these valuable suggestions. We have addressed potential selection bias by explicitly acknowledging the use of a convenience sample and its implications for generalizability in the limitations section. Although BMI was the only nutritional measure used, we now discuss the limitations of this approach and the absence of complementary anthropometric or metabolic indicators. The validity of the IPAQ-SF for university students has been supported with relevant literature, including the PaLS study, now cited. We added details on the SEBTm test environment, the training of evaluators, the inclusion of a familiarization trial, and the method used to determine limb dominance (self-reported kicking leg). The binary classification of physical activity, based on WHO thresholds, is acknowledged as a simplification, and the implications are discussed. Lastly, we now report that key regression assumptions (linearity, normality of residuals, homoscedasticity, and multicollinearity) were assessed and met.

Comment 3:
The Result section is logically organized but lacks essential statistical metrics (e.g., effect sizes, confidence intervals), reducing result interpretability. While sex-based subgroup analysis is included, the absence of interaction testing limits insights into moderating effects. Balance tests focus only on one limb and three directions, overlooking asymmetries and broader movement patterns. Figures lack confidence intervals and significance markers. The regression model includes only three predictors, omitting key confounders (e.g., sleep, exercise history, mental health), weakening its explanatory power.

Response 3:
We thank the reviewer for these helpful observations. We address the constraint of analyzing only the dominant limb and three SEBTm directions, noting the potential for asymmetries and the need for future studies to explore more comprehensive movement patterns.  We recognize that the regression model included a limited number of predictors. While focused on BMI, PAL, and sex, we now acknowledge the omission of other relevant confounders and recommend their inclusion in future research.

 

Comment 4:
The discussion reiterates findings without offering sufficient theoretical interpretation or cross-study comparisons. Explanations for sex differences in balance (e.g., muscle mass, physical activity habits) are reasonable but superficial; deeper physiological or neuroendocrine factors are not addressed. The rationale for the non-significant anterior direction is speculative and unsupported by literature. Study limitations are acknowledged but not critically examined—sampling bias, questionnaire limitations, and untested measurement assumptions are mentioned without sufficient elaboration. Furthermore, the potential clinical or public health implications of the findings are not discussed, nor is their relevance to broader populations beyond the specific demographic studied.

Response 4:
Thank you for this comprehensive and constructive feedback. The Discussion section has been revised to improve theoretical interpretation and incorporate relevant cross-study comparisons. We expanded on the explanation for sex differences in postural balance by referencing literature on neuromuscular and hormonal factors. The reasoning for the non-significant anterior direction has been reformulated and supported by recent studies suggesting that this direction may be less sensitive to balance impairments. The limitations section has been strengthened with critical reflection on sampling bias, use of self-reported questionnaires, and potential measurement assumptions. Lastly, we now explicitly discuss the potential public health and educational applications of incorporating balance assessments into early screening strategies, as well as the generalizability of our findings to other populations.

 

Comment 5:
The authors assessed nutritional status solely using BMI, which is a limited approach that does not comprehensively reflect nutritional condition, such as body fat distribution, dietary intake, or metabolic indicators. Therefore, the term "Nutritional Status" in the title may be overly broad. It is recommended to revise the title for greater accuracy and alignment with the study content, for example: "Body Mass Index and Physical Activity Level as Determinants of Dynamic Postural Balance in Young Adults."

Response 5:
We appreciate the reviewer’s suggestion regarding the title terminology. In response to similar feedback from other reviewers, we have revised the title to:
"Relationship of Nutritional Status and Physical Activity Level with Dynamic Postural Balance in Young Adults."
This version better reflects the correlational nature of the study, rather than implying a causal or predictive model, and responds to concerns about clarity and scientific framing.

Regarding the continued use of the term “nutritional status”, we acknowledge that BMI is a limited indicator that does not capture all dimensions of nutritional health, such as fat distribution, metabolic profile, or dietary quality. However, we note that BMI is widely recognized in clinical and public health research as a practical and valid proxy for nutritional status, especially in large-scale or field-based studies where more comprehensive assessments are not feasible. Numerous international guidelines, including those from the WHO, continue to classify individuals into nutritional categories (e.g., underweight, normal weight, overweight, obese) based solely on BMI.

In our manuscript, we clearly state that nutritional status was determined using BMI, and we transparently acknowledge its limitations in the discussion and limitations sections. Therefore, we believe the use of the term “nutritional status” remains appropriate and justified within the context and scope of the present study. This also maintains alignment with the terminology commonly used in epidemiological and kinesiology literature when BMI is the primary anthropometric indicator applied.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for the improved version of your paper. Congratulations!

Reviewer 2 Report

Comments and Suggestions for Authors

MANUSCRIPT OK

Comments on the Quality of English Language

GOOD

Reviewer 3 Report

Comments and Suggestions for Authors

I screened the revised manuscript and I think that the revisions are correctly applied. 

Reviewer 4 Report

Comments and Suggestions for Authors

The authors have made clear and substantial improvements in response to prior review comments. The introduction is now more concise and focused; methodological details such as sampling rationale, assessment procedures, and regression models have been clarified; results are presented more effectively; and the title has been revised to avoid overstatement. While some aspects (e.g., reliance on BMI, limited literature diversity, and theoretical depth) could still be further enhanced, the manuscript overall has improved significantly and sufficiently addresses key reviewer concerns. I recommend accepting the revised manuscript for publication.