Nutritional Care Process in Hospitalized Patients with Obesity-Related Multimorbidity

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This review provides recommendations on the nutritional care process, including assessing nutritional status, estimating nutritional requirements, and offering guidance on nutritional management for hospitalized patients with obesity-related multimorbidity. The paper integrates a substantial amount of relevant guidelines and recent findings, adding significant value to the field.

Below are several suggestions for the authors to consider:

1. The review presents detailed recommendations across various areas within each section. However, it may not be immediately clear to readers how each recommendation fits into the overall nutritional care process. Including a summary flowchart or diagram that provides a high-level overview of the care process and key considerations would enhance clarity and help readers better understand how the individual components are interconnected.
2. Related to the above suggestion, certain sections may lack some background content for the readers.
   • Sections 3 and 4 address nutritional screening and assessment, respectively. However, the relationship between these two concepts is not clearly explained. Before delving into the specific elements of Section 4, consider adding background context at the beginning of this section to clarify how assessment follows screening within the overall nutritional care process, and to distinguish the purposes of each.
   • Section 10 discusses the use of immunonutrients. Similarly, including a brief introductory explanation of their relevance and the clinical scenarios in which they are indicated would help orient the reader and strengthen the section’s coherence.
3. On lines 215–217, where the EFFORT study is mentioned, please ensure a proper citation is included in that sentence.
4. Some abbreviations are introduced without their full terms. Please ensure all abbreviations are clearly defined at first use. For instance, AMI and VET in Table 1 (p 9), and EFFORT in line 215.
5. The formatting of the Abbreviations section could be improved for better readability. In several instances (e.g., lines 368, 370, 374, etc.), the abbreviations and their definitions are placed closely together, which may hinder clarity. Adding consistent spacing between abbreviations and their explanations would enhance the overall presentation and readability of this section.

Author Response

RESPONSE LETTER REGARDING COMMENTS FROM REVIEWERS AND EDITOR

 

obesities-3643179

Mexico City, 16 may 2025.

 

Journal Obesities of Multidisciplinary Digital Publishing Institute (MDPI).

Dear Academic Editor and Reviewers

 

P R E S E N T

 

Thank you very much for your thoughtful response. We have thoroughly reviewed your comments and suggestions regarding the article entitled "Nutritional Care Process in Hospitalized Patients with Obesity-Related Multimorbidity" (Ms# obesities-3643179). We have addressed your observations and incorporated the necessary modifications into the revised manuscript. These changes are highlighted in red in the attached updated and revised manuscript.

Reviewer 1

Comments and Suggestions for Authors

This review provides recommendations on the nutritional care process, including assessing nutritional status, estimating nutritional requirements, and offering guidance on nutritional management for hospitalized patients with obesity-related multimorbidity. The paper integrates a substantial amount of relevant guidelines and recent findings, adding significant value to the field.

• Thank you very much for your kind comment.

Below are several suggestions for the authors to consider:

1. The review presents detailed recommendations across various areas within each section. However, it may not be immediately clear to readers how each recommendation fits into the overall nutritional care process. Including a summary flowchart or diagram that provides a high-level overview of the care process and key considerations would enhance clarity and help readers better understand how the individual components are interconnected.

• Thanks for the recommendation. We've added a diagram summarizing the nutritional care process in Figure 1. Lines: 480 to 486.

1. Related to the above suggestion, certain sections may lack some background content for the readers.
• Sections 3 and 4 address nutritional screening and assessment, respectively. However, the relationship between these two concepts is not clearly explained. Before delving into the specific elements of Section 4, consider adding background context at the beginning of this section to clarify how assessment follows screening within the overall nutritional care process, and to distinguish the purposes of each.

• Take a look line 139 to 148 We describe the relationship between nutritional screening and comprehensive nutritional assessment. We also add context at the beginning of Section 4 to clarify how comprehensive nutritional assessment follows screening within the overall nutritional care process.

 

• Section 10 discusses the use of immunonutrients. Similarly, including a brief introductory explanation of their relevance and the clinical scenarios in which they are indicated would help orient the reader and strengthen the section’s coherence.
• Take a look line 430 to 433. We include a brief introduction on the relevance and clinical scenarios in which immunonutrient supplementation is indicated.

 

1. On lines 215–217, where the EFFORT study is mentioned, please ensure a proper citation is included in that sentence.

• Take a look line 263 to 267. The meaning of the acronym EFFORT and the corresponding citations were added.

 

1. Some abbreviations are introduced without their full terms. Please ensure all abbreviations are clearly defined at first use. For instance, AMI and VET in Table 1 (p 9), and EFFORT in line 215.

• Table 2 VET was changed to its correct acronym TEE: Total Energy Expenditure. On Lines 415 Added definition of the abbreviation AMI: Acute Myocardial Infarction. On lines 263 The meaning of the acronym EFFORT has been added. Thank you for your detailed comments.

 

5. The formatting of the Abbreviations section could be improved for better readability. In several instances (e.g., lines 368, 370, 374, etc.), the abbreviations and their definitions are placed closely together, which may hinder clarity. Adding consistent spacing between abbreviations and their explanations would enhance the overall presentation and readability of this section.

 

• Take a look line 522 to 578, We've improved the formatting of the abbreviations section to make it easier to read.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,
Thank you for your fascinating manuscript.
This manuscript presents a comprehensive and clinically relevant narrative review on applying the Nutrition Care Process (NCP) for hospitalised individuals with obesity-related multimorbidity. The topic is timely and significant, given the growing need for standardised nutritional strategies in complex inpatient populations. The manuscript is well-organised and references authoritative sources (ESPEN, ASPEN, etc.), but several areas need clarification and improvement to enhance its clarity, practical value, and critical perspective. The review’s current strength lies in its detailed content and clinical relevance. However, its main limitation is a lack of synthesis and critical appraisal of the evidence. The following suggestions help the authors improve the manuscript before publication.

Title and Abstract

1. Please clarify the specific aim of the review. For example, are you proposing a framework, summarising existing guidelines, or highlighting research gaps?
2. The abstract should end with a more explicit statement of the manuscript’s purpose and key conclusions.

Introduction

1. Consider including a more concise and structured summary of the rationale for using the NCP in this population.

2. Define the scope and target audience early in the introduction (e.g., clinical dietitians, hospital nutrition support teams).

Main Body

Section 3–4: NCP and Nutritional Assessment

The discussion of screening and assessment tools is thorough. However, the PES format is mentioned only briefly. Please expand this section with an example of a PES diagnosis for a typical hospitalised patient with obesity (e.g., “Inadequate protein-energy intake related to reduced appetite and chronic inflammation as evidenced by 5% weight loss and hypoalbuminemia”).

Section 5: Estimation of Requirements

This section is rich in formulas and clinical parameters, which is excellent. However, the critical analysis of differing recommendations (e.g., protein dosing >2.5 g/kg IBW in class III obesity) could be improved. Consider noting that these are debated and may not be appropriate for all patients.

Section 6–8: Diet Therapy, ONS, and EN/PN

These sections are highly informative. However, they can benefit from simplified language and better visual formatting. Consider dividing Table 1 or highlighting key data with a summary figure or colour-coded table.

Section 9: Parenteral Nutrition

Please briefly comment on the risks of overfeeding and infection in PN and the importance of monitoring. Also, clarify how protein-energy targets are adjusted for metabolic stress in the context of obesity.

Section 10: Immunonutrition and Micronutrients

There is a good breadth of coverage. However, some dosages are mentioned without context. For glutamine/arginine or vitamin D3, indicate whether supplementation is widely supported or still under investigation.

Multimorbidity

One of the manuscript’s goals is to address obesity-related multimorbidity. Still, the discussion would benefit from a short clinical scenario illustrating how recommendations might conflict (e.g., fluid restriction for heart failure vs. high protein for sarcopenia).

Discussion/Conclusion

The conclusion effectively summarises key challenges, but would be stronger with:

• 1. A more straightforward call for standardised guidelines specific to this patient group.

  2. Identification of research gaps (e.g., protein dosing stratified by obesity class; efficacy of immunonutrition in sarcopenic obesity).

  3. A more defined take-home message for clinicians.

Tables and Figures

Table 1 is detailed but difficult to navigate in its current format. Consider breaking it into thematic blocks or simplifying the structure. In addition, if space permits, add a summary flowchart of the NCP as applied to this population.

Language and Style

Many paragraphs are dense. Shortening sentences and improving transitions would enhance readability. Ensure consistent use of terms (ORM, ORCDDS) and abbreviations. Provide a glossary if necessary.

Comments on the Quality of English Language

The language requires moderate editing for clarity and readability. Many sentences are long and overly complex, which may hinder comprehension for an international or interdisciplinary audience. Simplifying sentence structure, improving transitions, and ensuring consistency in terminology would significantly enhance the manuscript’s accessibility and professional tone. I recommend professional English language editing before publication.

Author Response

RESPONSE LETTER REGARDING COMMENTS FROM REVIEWERS AND EDITOR

 

obesities-3643179

Mexico City, 16 may 2025.

 

Journal Obesities of Multidisciplinary Digital Publishing Institute (MDPI).

Dear Academic Editor and Reviewers

 

P R E S E N T

 

Thank you very much for your thoughtful response. We have thoroughly reviewed your comments and suggestions regarding the article entitled "Nutritional Care Process in Hospitalized Patients with Obesity-Related Multimorbidity" (Ms# obesities-3643179). We have addressed your observations and incorporated the necessary modifications into the revised manuscript. These changes are highlighted in red in the attached updated and revised manuscript.

 

Reviewer 2

 

Comments and Suggestions for Authors

Dear Authors,
Thank you for your fascinating manuscript.
This manuscript presents a comprehensive and clinically relevant narrative review on applying the Nutrition Care Process (NCP) for hospitalised individuals with obesity-related multimorbidity. The topic is timely and significant, given the growing need for standardised nutritional strategies in complex inpatient populations. The manuscript is well-organised and references authoritative sources (ESPEN, ASPEN, etc.), but several areas need clarification and improvement to enhance its clarity, practical value, and critical perspective. The review’s current strength lies in its detailed content and clinical relevance. However, its main limitation is a lack of synthesis and critical appraisal of the evidence. The following suggestions help the authors improve the manuscript before publication.

• Dear reviewer, thank you for sharing your valuable comments with us.

Title and Abstract

1. Please clarify the specific aim of the review. For example, are you proposing a framework, summarising existing guidelines, or highlighting research gaps?

• Take a look Abstract, we have clarified the specific objective

1. The abstract should end with a more explicit statement of the manuscript’s purpose and key conclusions.

• Take a look Abstract. We've clarified the purpose of the manuscript and the key conclusion. Thank you.

Introduction

1. Consider including a more concise and structured summary of the rationale for using the NCP in this population.

• Take a look line 46 to 49 We include a more concise summary to justify NCP in this population.

 

2. Define the scope and target audience early in the introduction (e.g., clinical dietitians, hospital nutrition support teams).

 

• Take a look line 67 to 71. We mentioned that this literature review is addressed to all healthcare professionals who make up the multidisciplinary nutritional support team.

Main Body

Section 3–4: NCP and Nutritional Assessment

The discussion of screening and assessment tools is thorough. However, the PES format is mentioned only briefly. Please expand this section with an example of a PES diagnosis for a typical hospitalised patient with obesity (e.g., “Inadequate protein-energy intake related to reduced appetite and chronic inflammation as evidenced by 5% weight loss and hypoalbuminemia”).

• Take a look new table 1 lines 241 to 247 are shown the Most common nutritional diagnoses in the population with Obesity-Related Multimorbidity.

Section 5: Estimation of Requirements

This section is rich in formulas and clinical parameters, which is excellent. However, the critical analysis of differing recommendations (e.g., protein dosing >2.5 g/kg IBW in class III obesity) could be improved. Consider noting that these are debated and may not be appropriate for all patients.

• In table 2, the recommendation of protein dosing >2.5 g/kg IBW in class III obesity was eliminated and in lines 251 to 255 the following is stated: group with a BMI of 30 to 39.9 kg/m² that received high protein doses (>2.2 g per kg of ABW per day) tended to have lower mortality compared to the group that received low doses (0.8 to 1.2 g/kg/day) (Heyland et al., 2023; Tweel et al., 2024).

Section 6–8: Diet Therapy, ONS, and EN/PN

These sections are highly informative. However, they can benefit from simplified language and better visual formatting. Consider dividing Table 1 or highlighting key data with a summary figure or colour-coded table.

 

• Thank you for the recommendation, we have divided the previous table 1 into two parts (look table 2 and 3) and have made a diagram that summarizes the nutritional care process in this population (look figure 1).

Section 9: Parenteral Nutrition

Please briefly comment on the risks of overfeeding and infection in PN and the importance of monitoring. Also, clarify how protein-energy targets are adjusted for metabolic stress in the context of obesity.

• Take a look line 409 to 412. The risks of overfeeding and infection in parenteral nutrition are briefly described.
• Take a look Table 2 column 3 specifies how energy and protein should be calculated according to the degree of metabolic stress in the context of obesity.

Section 10: Immunonutrition and Micronutrients

There is a good breadth of coverage. However, some dosages are mentioned without context. For glutamine/arginine or vitamin D3, indicate whether supplementation is widely supported or still under investigation.

Sección 10: Inmunonutrición y micronutrientes

• Take a look line 430 to 433. We have provided specifications for deciding on supplementation and pointed out that there are no specific studies in patients with obesity and multimorbidity.

 

Multimorbidity

One of the manuscript’s goals is to address obesity-related multimorbidity. Still, the discussion would benefit from a short clinical scenario illustrating how recommendations might conflict (e.g., fluid restriction for heart failure vs. high protein for sarcopenia).

• Take a look line 505 to 511. In the discussion section, we provided three clinical scenarios that illustrate how parenteral nutrition recommendations could be contradictory.

 

Discussion/Conclusion

The conclusion effectively summarises key challenges, but would be stronger with:

1. A more straightforward call for standardised guidelines specific to this patient group.
2. Identification of research gaps (e.g., protein dosing stratified by obesity class; efficacy of immunonutrition in sarcopenic obesity).
3. A more defined take-home message for clinicians.

• Take a look line 503 to 520. We clarify this message. Thank you.

 

Tables and Figures

Table 1 is detailed but difficult to navigate in its current format. Consider breaking it into thematic blocks or simplifying the structure. In addition, if space permits, add a summary flowchart of the NCP as applied to this population.

• We have divided the previous Table 1 into Table 2 and Table 3 to simplify its structure. We also created a flowchart summarizing the NCP in this population (look Figure 1).

Language and Style

Many paragraphs are dense. Shortening sentences and improving transitions would enhance readability. Ensure consistent use of terms (ORM, ORCDDS) and abbreviations. Provide a glossary if necessary.

Lenguaje y Estilo

• We've shortened sentences and improved transitions to make this article easier to read. We've also left the term ORM alone. Thank you very much for your suggestions for improvement.

Comments on the Quality of English Language

The language requires moderate editing for clarity and readability. Many sentences are long and overly complex, which may hinder comprehension for an international or interdisciplinary audience. Simplifying sentence structure, improving transitions, and ensuring consistency in terminology would significantly enhance the manuscript’s accessibility and professional tone. I recommend professional English language editing before publication.

• We've shortened sentences and improved transitions to improve the readability of this article. We've also submitted the text to professional English language editing.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Reviewer Report

Manuscript Title: Nutritional Care Process in Hospitalized Patients with Obesity-Related Multimorbidity
Authors: Rivera-Carranza et al.
Journal: Obesities
Recommendation: Major Revision

General Assessment

This narrative review addresses an increasingly important clinical challenge: the nutritional care process for hospitalized patients living with obesity and related multimorbidity (ORM). The topic is timely and relevant, given the growing burden of obesity-related chronic diseases globally. The manuscript provides a comprehensive overview of current recommendations and evidence-based strategies. However, despite the quality and scope of the content, the manuscript presents important limitations in methodological transparency, structural cohesion, and critical synthesis, which must be addressed before it can be considered for publication in a high-impact journal.

1. Abstract

Strengths:

• Clearly outlines the aim and general content of the article.

Weaknesses:

• Lacks specificity in terms of the methods used to select the reviewed literature.
• Overuses generalizations like “limited and heterogeneous evidence” without indicating where such limitations exist.

Recommendation: Clarify whether this is a scoping or narrative review and briefly mention how sources were selected.

2. Introduction

Strengths:

• Well contextualized public health relevance of obesity-related diseases in the hospital setting.
• Includes clear definitions of ORCDDs and their systemic implications.

Weaknesses:

• Redundant in some parts; similar ideas (e.g., long-term disability, economic burden) are repeated.
• Limited citation of high-impact, recent publications (e.g., no reference to WHO 2023–24 data).

Recommendation: Streamline content to avoid repetition, and reinforce arguments with recent global prevalence statistics or guideline references.

3. Structure and Scope of the Review

Strengths:

• Comprehensive coverage of the components of the Nutrition Care Process (NCP): screening, assessment, diagnosis, intervention, monitoring.

Weaknesses:

• The review lacks a clear methodological framework. There is no mention of the type of review (narrative, scoping, integrative) or search strategy.
• The rationale for selecting particular tools (e.g., NRS-2002 vs. GLIM) is insufficiently justified.
• No table or figure is included summarizing the care process steps or decision-making algorithms.

Recommendation:
Add a brief description of literature identification and selection strategy. Consider including summary tables or figures (e.g., flowchart of NCP application).

4. Quality and Depth of Evidence

Strengths:

• Excellent integration of ESPEN, ASPEN, and other clinical nutrition guidelines.
• Detailed dietary calculations for different clinical conditions.

Weaknesses:

• Some recommendations (e.g., specific grams of macronutrients, percentages for ICU patients) are extremely detailed but lack references or are based on single studies.
• Several sections include very technical content (e.g., equations for creatinine index, nitrogen balance) without context for clinical interpretation.

Recommendation: Ensure that all clinical recommendations are properly referenced and clarify which are consensus-based vs. evidence-based.

5. Clinical Relevance and Innovation

Strengths:

• Addresses a neglected population: hospitalized patients with obesity and multimorbidity.
• Advocates for personalized care and evidence-based screening.

Weaknesses:

• The review could benefit from deeper analysis of implementation challenges in low- and middle-income countries.
• Lacks critical comparison between existing tools (e.g., SGA vs. GLIM) and their applicability in ORM.

Recommendation: Add discussion on barriers to implementation and comparative effectiveness of tools in real-world clinical settings.

6. Writing Style and Organization

Strengths:

• Technical vocabulary is appropriate for an academic audience in nutrition and clinical care.

Weaknesses:

• Some sections are overly long and include dense technical descriptions (e.g., medical nutrition therapy tables), which might be better placed in appendices or supplementary files.
• Occasional grammatical errors and awkward phrasing (e.g., “hospital diet should consider the three main meals…”).

Recommendation: Simplify sentence structure in complex paragraphs and consider restructuring the text for clarity and reader engagement.

7. References

Strengths:

• Substantial number of references (>80), including high-quality sources (ESPEN, AACE, ADA, ASPEN).

Weaknesses:

• Heavy reliance on guidelines published before 2021. Limited citation of the most recent studies from 2023–2024.
• Reference formatting inconsistencies in DOI presentation.

Recommendation: Update with the most recent literature where possible and standardize citation style.

 

Author Response

RESPONSE LETTER REGARDING COMMENTS FROM REVIEWERS AND EDITOR

 

obesities-3643179

Mexico City, 16 may 2025.

 

Journal Obesities of Multidisciplinary Digital Publishing Institute (MDPI).

Dear Academic Editor and Reviewers

 

P R E S E N T

 

Thank you very much for your thoughtful response. We have thoroughly reviewed your comments and suggestions regarding the article entitled "Nutritional Care Process in Hospitalized Patients with Obesity-Related Multimorbidity" (Ms# obesities-3643179). We have addressed your observations and incorporated the necessary modifications into the revised manuscript. These changes are highlighted in red in the attached updated and revised manuscript.

Reviewer 3

 

Comments and Suggestions for Authors

Reviewer Report

Manuscript Title: Nutritional Care Process in Hospitalized Patients with Obesity-Related Multimorbidity
Authors: Rivera-Carranza et al.
Journal: Obesities
Recommendation: Major Revision

General Assessment

This narrative review addresses an increasingly important clinical challenge: the nutritional care process for hospitalized patients living with obesity and related multimorbidity (ORM). The topic is timely and relevant, given the growing burden of obesity-related chronic diseases globally. The manuscript provides a comprehensive overview of current recommendations and evidence-based strategies. However, despite the quality and scope of the content, the manuscript presents important limitations in methodological transparency, structural cohesion, and critical synthesis, which must be addressed before it can be considered for publication in a high-impact journal.

1. Abstract

Strengths:

• Clearly outlines the aim and general content of the article.

Weaknesses:

• Lacks specificity in terms of the methods used to select the reviewed literature.
• Overuses generalizations like “limited and heterogeneous evidence” without indicating where such limitations exist.

Recommendation: Clarify whether this is a scoping or narrative review and briefly mention how sources were selected.

• Take a look line 28, 67 to 83. These points are clarified.

 

1. Introduction

Strengths:

• Well contextualized public health relevance of obesity-related diseases in the hospital setting.
• Includes clear definitions of ORCDDs and their systemic implications.

Weaknesses:

• Redundant in some parts; similar ideas (e.g., long-term disability, economic burden) are repeated.
• Limited citation of high-impact, recent publications (e.g., no reference to WHO 2023–24 data).

Recommendation: Streamline content to avoid repetition, and reinforce arguments with recent global prevalence statistics or guideline references.

 

• Thank you for your feedback. We've made the requested changes to the introduction section.

 

1. Structure and Scope of the Review

Strengths:

• Comprehensive coverage of the components of the Nutrition Care Process (NCP): screening, assessment, diagnosis, intervention, monitoring.

Weaknesses:

• The review lacks a clear methodological framework. There is no mention of the type of review (narrative, scoping, integrative) or search strategy.
• The rationale for selecting particular tools (e.g., NRS-2002 vs. GLIM) is insufficiently justified.
• No table or figure is included summarizing the care process steps or decision-making algorithms.

Recommendation:
Add a brief description of literature identification and selection strategy. Consider including summary tables or figures (e.g., flowchart of NCP application).

 

• Take a look line 28, 67-70. The type of review and search strategy are mentioned.
• Take a look line 139-148. The use of NRS-2002 and the difference between GLIM criteria are specified with bibliographic references.
• Take a look figure 1. NCP passes are summarized using decision-making algorithms. Thank you.

 

1. Quality and Depth of Evidence

Strengths:

• Excellent integration of ESPEN, ASPEN, and other clinical nutrition guidelines.
• Detailed dietary calculations for different clinical conditions.

Weaknesses:

• Some recommendations (e.g., specific grams of macronutrients, percentages for ICU patients) are extremely detailed but lack references or are based on single studies.
• Several sections include very technical content (e.g., equations for creatinine index, nitrogen balance) without context for clinical interpretation.

Recommendation: Ensure that all clinical recommendations are properly referenced and clarify which are consensus-based vs. evidence-based.

• Thank you very much for your comments on improvements. The levels of evidence have been added to Tables 2 and 3. Take a look at lines 72 to 83, where the meaning of the level of evidence is explained. The interpretation of nitrogen balance (NB) has been added to lines 199-204. It was also decided to remove creatinine from calculating the creatinine-height index (CHI) because it is no longer used.

1. Clinical Relevance and Innovation

Strengths:

• Addresses a neglected population: hospitalized patients with obesity and multimorbidity.
• Advocates for personalized care and evidence-based screening.

Weaknesses:

• The review could benefit from deeper analysis of implementation challenges in low- and middle-income countries.
• Lacks critical comparison between existing tools (e.g., SGA vs. GLIM) and their applicability in ORM.

Recommendation: Add discussion on barriers to implementation and comparative effectiveness of tools in real-world clinical settings.

• We could propose other strategies without evidence to adjust treatment to the economic, social, political, geographic, etc. challenges in low- and middle-income countries, but that is not the objective of our review. The objective of our review is to present universal evidence-based recommendations for ORM, i.e., "what should be done according to the evidence."
• Take at look at lines 138-144. The recommendation to implement the Malnutrition Screening Tool (MST) and the Subjective Global Assessment (SGA) has been removed since there is no evidence in ORM. Thank you.

1. Writing Style and Organization

Strengths:

• Technical vocabulary is appropriate for an academic audience in nutrition and clinical care.

Weaknesses:

• Some sections are overly long and include dense technical descriptions (e.g., medical nutrition therapy tables), which might be better placed in appendices or supplementary files.
• Occasional grammatical errors and awkward phrasing (e.g., “hospital diet should consider the three main meals…”).

Recommendation: Simplify sentence structure in complex paragraphs and consider restructuring the text for clarity and reader engagement.

 

• We have simplified the structure of sentences and paragraphs for easier reading.
• Take a look line 305 to 396 used to be “hospital diet should consider the three main meals” now is “The hospital food service should offer the 3 major meals”.
• We have simplified the previous table 1 into tables 2 and 3 to simplify its organization. Thank you.

 

References

Strengths:

• Substantial number of references (>80), including high-quality sources (ESPEN, AACE, ADA, ASPEN).

Weaknesses:

• Heavy reliance on guidelines published before 2021. Limited citation of the most recent studies from 2023–2024.
• Reference formatting inconsistencies in DOI presentation.

Recommendation: Update with the most recent literature where possible and standardize citation style.

• Take a look line 67 to 61. We have selected the most current clinical practice guidelines from 2020 to 2025.
• Take a look references section. We have corrected formatting inconsistencies in DOI presentation. Thank you so much.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have clearly and thoroughly addressed my questions, both within the revised manuscript and by directly referencing them in the cover letter. The additional context provided has improved the overall clarity and understanding of the work. At this point, I have no further questions.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

thank you for your effort. Now the manuscript has been sufficiently improved. 

Thank you!

Reviewer 3 Report

Comments and Suggestions for Authors

General Evaluation of the Authors' Response to Reviewer 3

The authors have, overall, responded appropriately and thoroughly to the comments provided by Reviewer 3. Below is a detailed assessment of the adequacy of each response:

1. Abstract

Reviewer Comment: The abstract lacks specificity regarding the type of review and literature selection methodology.
Authors’ Response: Clarifications were made in lines 28 and 67–83.
✅ Assessment: Adequate. The authors clearly indicate where the requested information was added.

2. Introduction

Reviewer Comment: The section includes redundant statements and lacks updated references (e.g., WHO 2023–24).
Authors’ Response: The authors state that redundancies were removed and recent data incorporated.
✅ Assessment: Adequate. While specific new references are not listed in the response, the general improvements are acknowledged and properly located.

3. Structure and Scope of the Review

Reviewer Comment: The manuscript lacks a clear methodological framework and rationale for tool selection; figures or tables are recommended.
Authors’ Response: The review type and search strategy are specified (lines 28, 67–70), and justification for tool selection is provided (lines 139–148). A decision-making algorithm was added in Figure 1.
✅ Assessment: Highly adequate. The authors provide precise locations of revisions and enrich the manuscript with a visual summary.

4. Quality and Depth of Evidence

Reviewer Comment: Some recommendations lack references or are overly technical without clinical interpretation.
Authors’ Response: Levels of evidence were added to Tables 2 and 3; the interpretation of nitrogen balance was clarified (lines 199–204); the creatinine-height index was removed.
✅ Assessment: Highly adequate. The authors addressed both transparency and clinical usability with appropriate revisions.

5. Clinical Relevance and Innovation

Reviewer Comment: There is insufficient discussion of implementation barriers in low- and middle-income countries (LMICs), and a lack of critical comparison between nutritional assessment tools.
Authors’ Response: The authors declined to propose strategies unsupported by evidence, in line with the scope of their review. They removed references to tools lacking evidence in the target population (lines 138–144).
🟡 Assessment: Partially adequate. While the authors’ rationale is methodologically sound, a brief discussion acknowledging real-world challenges or limitations in LMIC settings—even without proposing solutions—would have enhanced the clinical relevance. It is also unclear whether a comparative analysis of tools (e.g., GLIM vs. SGA) was sufficiently expanded.

6. Writing Style and Organization

Reviewer Comment: Some sections are overly dense or technical and could benefit from restructuring or relegation to appendices.
Authors’ Response: Sentence structures were simplified, and technical tables were reorganized for clarity (e.g., line 305–396, new Tables 2 and 3).
✅ Assessment: Adequate. Structural and stylistic revisions were effectively implemented to improve readability.

7. References

Reviewer Comment: Over-reliance on pre-2021 guidelines; inconsistencies in DOI formatting.
Authors’ Response: References were updated to include 2020–2025 guidelines; formatting issues were corrected.
✅ Assessment: Adequate. The response addresses both currency and consistency of references.

Overall Conclusion

The authors have submitted a comprehensive and thoughtful rebuttal. They:

• Precisely identify the lines where revisions were made.
• Justify the rationale behind each change or non-change.
• Enhance the manuscript’s methodological transparency, evidentiary support, and editorial quality.

The only partially addressed concern is the lack of a broader contextual discussion on the implementation challenges in low-resource settings, which could have been briefly acknowledged to strengthen the article’s global applicability.

Final Verdict:

The authors’ responses are, on the whole, satisfactory and address the reviewer’s concerns in a detailed and constructive manner. The revised manuscript is now likely suitable for publication, assuming no further major concerns from other