A Combination of Insufficient Physical Activity and Sedentary Behavior Associated with Dynapenic Abdominal Obesity and Dynapenic Obesity in Older Adults: A Cross-Sectional Analysis

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Introduction:
The introduction would benefit from a clearer justification of the importance of examining the combined effects of insufficient physical activity (PA) and sedentary behavior (SB). Although both are discussed independently, the rationale for studying their unique combined impact warrants further elaboration.

I think it is necessary to provide a clear justification of the importance of examining the combined effects of insufficient PA and SB. I see both are discussed independently but the rationale for studying the combined impact needs furtuer discussion.

Method
I understand the categorization of PA and SB into four distinct groups; however, the rationale for selecting specific cut-off points (e.g., 342.85 min/day for sedentary behavior) requires additional justification. 

Please provide rationale for excluding participants with cognitive impairment 

Results:
Tables: The tables contain more detail than necessary, complicating interpretation. It is necessary to simplify the tables to include only essential data (e.g., adjusted prevalence ratios and confidence intervals). 

Discussion:
It is necessary to provide practical implications, specifically addressing how the findings could inform targeted public health policies or interventions for older adults.

Additionally, limitations should be discussed more comprehensively. Currently, issues such as indirect measurement of PA and SB are mentioned briefly; potential biases associated with self-reported measures (IPAQ) should be explicitly addressed.

Suggestions for future research might include recommending longitudinal studies to better assess causality, as the cross-sectional design used here limits conclusions regarding directionality.

Author Response

1. Reviewer 1 - Comments to the Author
1.1. Introduction: The introduction would benefit from a clearer justification of the importance of examining the combined effects of insufficient physical activity (PA) and sedentary behavior (SB). Although both are discussed independently, the rationale for studying their unique combined impact warrants further elaboration. I think it is necessary to provide a clear justification of the importance of examining the combined effects of insufficient PA and SB. I see both are discussed independently but the rationale for studying the combined impact needs furtuer discussion.
Response: Dear Reviewer, thank you very much for your time, availability, and careful review of our manuscript. In response to your request, we have expanded the justification for our study, as detailed below.
“Insufficient physical activity (PA) and prolonged sedentary behavior (SB) appear to exacerbate the physiological effects of aging [11]. Both behaviors are independently associated with dynapenia [12] and obesity [13] in older adults. Consequently, it is plausible to hypothesize that the combination of insufficient PA and high SB is associated with an increased likelihood of DAO and DO. However, despite the recognized independent associations, a notable gap exists in epidemiological research specifically investigating the combined effect of insufficient PA and high SB on DAO and DO in older adults.
Addressing this gap through population-based health surveys is crucial, as findings can inform health surveillance actions and facilitate more targeted interventions by elucidating the impact of these behavioral patterns on the physical performance and nutritional status of older populations. Therefore, this study aimed to investigate the association between combined PA levels and SB with DAO and DO in older adults.”

1.2. Method: I understand the categorization of PA and SB into four distinct groups; however, the rationale for selecting specific cut-off points (e.g., 342.85 min/day for sedentary behavior) requires additional justification. Please provide rationale for excluding participants with cognitive impairment.
Response: Dear Reviewer, thank you for your pertinent and thoughtful comments. The classification of physical activity levels is well established in the literature, with cut-off points recommended by the World Health Organization. However, there remains a lack of consensus regarding the definition of high sedentary behavior exposure in older adults. As a result, the 75th percentile is frequently adopted in the literature, as it represents the upper quartile of time spent in sedentary activities — a level associated with greater adverse health outcomes in this population. To enhance clarity, we have now included a detailed justification for this methodological choice in the Methods section (Section 2.5) of the manuscript.

“2.5. Independent Variables
PA was assessed using the first four domains of the long-form International Physical Activity Questionnaire (IPAQ) [20], an instrument validated for Brazilian older adults [21, 22]. The weekly duration (minutes/week) of moderate-to-vigorous PA across work, transportation, domestic activities, and leisure-time domains was summed [23]. Participants were then classified as either insufficiently active (< 150 minutes/week of total PA) or sufficiently active (≥ 150 minutes/week) [24].
SB was evaluated using the IPAQ's fifth domain, which captures time spent sitting or reclining while awake on weekdays and weekend days [20]. A weighted average of daily SB was calculated using the formula: [(weekday sitting duration × 5) + (weekend sitting duration × 2)] / 7 [23]. High SB was defined as being at or above the 75th percentile of this weighted average, corresponding to ≥ 342.85 minutes/day [25]. This approach, utilizing a percentile of the distribution within the study population, is commonly employed in epidemiological studies to identify the group with the highest exposure to the behavior when universal, clinically established cut-off points are not available for the specific measurement method and population.
Based on their PA and SB levels, participants were stratified into four groups: G1) sufficiently active and low SB; G2) sufficiently active and high SB; G3) insufficiently active and low SB; and G4) insufficiently active and high SB [26].”
The exclusion of older adults with cognitive impairment was adopted to minimize potential bias in the collection of self-reported information, as such data are particularly susceptible to memory bias. To address your suggestion and enhance transparency for readers, we have included a justification for this criterion in the Methods section and have further elaborated on its implications in the Discussion.

Methods:
“2.3. Eligibility Criteria
Participants were recruited based on the following inclusion criteria: aged 60 years or older, community-dwelling, and permanent residence within Aiquara’s urban boundaries [2]. Exclusion criteria included: cognitive impairment, assessed using the validated abbreviated Mini-Mental State Examination (MMSE) [17] with a cutoff score of ≤ 12 [18];being bedridden; or having neurological or auditory disorders [2]. These criteria were implemented to ensure data integrity, precision, and participants' complete comprehension of research protocols.”
Discussion:
“Notwithstanding these limitations, the present study also possesses notable strengths. One such strength is the use of the MMSE as a criterion to exclude older adults with cognitive impairment, thereby aiming to minimize potential recall bias in the self-reported measures. Another strength lies in the assessment of muscle strength through HGS, a method considered a gold standard for evaluating muscle weakness in older adults [39]. The census-based recruitment approach adopted in this research is also noteworthy, as this strategy enabled the investigation of associations between insufficient PA combined with high SB exposure and DAO and DO in a population of older adults living in a small-sized municipality in an understudied region of Northeastern Brazil.”

1.3. Results - Tables: The tables contain more detail than necessary, complicating interpretation. It is necessary to simplify the tables to include only essential data (e.g., adjusted prevalence ratios and confidence intervals).
Response: Dear Reviewer, thank you very much for your valuable guidance regarding the presentation of the results. We agree that Table 2 contained an excessive amount of information. In response to your suggestion, we have reconstructed the table to emphasize the adjusted measures of association and their respective 95% confidence intervals, thereby enhancing clarity and readability.

1.4. Discussion: It is necessary to provide practical implications, specifically addressing how the findings could inform targeted public health policies or interventions for older adults. Additionally, limitations should be discussed more comprehensively. Currently, issues such as indirect measurement of PA and SB are mentioned briefly; potential biases associated with self-reported measures (IPAQ) should be explicitly addressed. Suggestions for future research might include recommending longitudinal studies to better assess causality, as the cross-sectional design used here limits conclusions regarding directionality.
Response: Dear Reviewer, thank you for your insightful comments, which were instrumental in helping us recognize the need to more clearly articulate our study’s limitations, strengths, clinical applicability, and suggestions for future research. We are extremely grateful for your constructive input. In response, we have revised the concluding section of the Discussion, as presented below.
“Despite its valuable contributions, this study has limitations that should be acknowledged when interpreting the findings. First, PA and SB were evaluated using a self-report questionnaire (IPAQ). While the IPAQ is a widely used instrument in epidemiological studies, it provides an indirect measure of these behaviors and is subject to potential recall and social desirability biases. Furthermore, it primarily captures total time spent in different intensity levels and does not fully account for sedentary time patterns, such as the frequency and duration of breaks in sedentary time. Second, the study population consisted of older adults residing in a specific small municipality in Northeastern Brazil. Although the census-based approach allowed for a comprehensive investigation within this context, the demographic, socioeconomic, and cultural characteristics of this population may limit the direct generalizability of our findings to older adults in significantly different geographical, socioeconomic, or healthcare access settings. However, these results are likely relevant for municipalities with similar profiles.
Further investigation into how specific local socio-cultural, economic, or environmental characteristics (e.g., access to health services, predominant cultural norms related to PA, or aspects of the built environment) might modulate these associations in diverse settings would enhance the applicability of these findings. Finally, despite controlling for several important potential confounding variables, the possibility of residual confounding by unmeasured factors (e.g., detailed dietary intake, specific chronic disease severity or duration, lifetime PA/SB trajectories) cannot be entirely excluded.
Notwithstanding these limitations, the present study also possesses notable strengths. One such strength is the use of the MMSE as a criterion to exclude older adults with cognitive impairment, thereby aiming to minimize potential recall bias in the self-reported measures. Another strength lies in the assessment of muscle strength through HGS, a method considered a gold standard for evaluating muscle weakness in older adults [39]. The census-based recruitment approach adopted in this research is also noteworthy, as this strategy enabled the investigation of associations between insufficient PA combined with high SB exposure and DAO and DO in a population of older adults living in a small-sized municipality in an understudied region of Northeastern Brazil.
The findings of this research, demonstrating a strong association between the combination of insufficient PA and high SB exposure and a substantially higher prevalence of DAO and DO in older adults, carry significant practical implications for public health and clinical practice. While traditional interventions often prioritize increasing PA, our results
highlight the critical need for dual approaches that simultaneously promote increased activity levels and a substantial reduction in time spent sedentary. Health professionals, particularly those working in primary care settings and contexts with limited resources, can utilize validated questionnaires, such as the IPAQ (employed in this study), to screen older adults for both PA levels and sedentary time. Identifying individuals who present this unfavorable combination of behaviors (insufficient PA and high SB) allows for targeting more specific and potentially more effective interventions.
Public health policies and health promotion programs aimed at the older adult population should, therefore, incorporate messaging and strategies that emphasize the importance of 'moving more and sitting less' throughout the day, extending beyond structured exercise sessions alone. Tailored, combined interventions, which might include community programs promoting both regular exercise (incorporating strength training appropriate for older adults) and practical strategies to reduce and interrupt daily sitting time (such as educational campaigns on the benefits of regular movement breaks and improvements in community walkability), could be instrumental in the prevention and management of dynapenic obesity, which represents a considerable health challenge in older populations, especially in municipalities with socioeconomic and healthcare access characteristics similar to Aiquara, Bahia, Brazil. Understanding these associations in such contexts provides a foundation for developing localized, impactful health initiatives.
Collectively, the findings of this research suggest etiological hypotheses regarding the influence of combined insufficient PA and high SB exposure on DAO and DO in older adults. These findings may provide a robust foundation for future epidemiological research. Longitudinal studies, such as prospective cohorts, are crucial to more definitively establish temporal relationships and the magnitude of risk. Such studies should ideally incorporate objective measures of PA and SB (e.g., accelerometers) to overcome self-report limitations and better characterize activity and sedentary patterns (including breaks in sedentary time). Furthermore, future research could also explore the efficacy of multifaceted interventions designed to mitigate these combined risks in older populations.”

Reviewer 2 Report

Comments and Suggestions for Authors

This is my review on your manuscript.

This study examines how body fat, muscle strength, and physical activity interact over time in aging populations.

In the introduction you should further explain why this specific combination of variables (adiposity, strength, and activity) was chosen and clarify what previous studies lacked and how this study addresses those gaps.

Is this an observational cohort, prospective, or retrospective analysis?

How confounders (comorbidities, baseline activity levels etc.) were controlled?

You should integrate graphs to show how adiposity, strength, and activity change over time.

Address whether responses differ by gender, baseline fitness, or other demographics and discuss consistency or discrepancies with other longitudinal studies.

Author Response

2. Reviewer 2 - Comments to the Author
2.1. This study examines how body fat, muscle strength, and physical activity interact over time in aging populations. In the introduction you should further explain why this specific combination of variables (adiposity, strength, and activity) was chosen and clarify what previous studies lacked and how this study addresses those gaps.
Response: Dear Reviewer, thank you for your time and for your careful review of our manuscript. In response to your request, we have revised the Introduction to more clearly articulate the gap identified in the literature and to strengthen the justification for our study, as detailed below.
“Insufficient physical activity (PA) and prolonged sedentary behavior (SB) appear to exacerbate the physiological effects of aging [11]. Both behaviors are independently associated with dynapenia [12] and obesity [13] in older adults. Consequently, it is plausible to hypothesize that the combination of insufficient PA and high SB is associated with an increased likelihood of DAO and DO. However, despite the recognized independent associations, a notable gap exists in epidemiological research specifically investigating the combined effect of insufficient PA and high SB on DAO and DO in older adults.
Addressing this gap through population-based health surveys is crucial, as findings can inform health surveillance actions and facilitate more targeted interventions by elucidating the impact of these behavioral patterns on the physical performance and nutritional status of older populations. Therefore, this study aimed to investigate the association between combined PA levels and SB with DAO and DO in older adults.”

2.2. Is this an observational cohort, prospective, or retrospective analysis?
Response: Dear Reviewer, thank you for your request for clarification regarding the study design. As described in the “Study design, setting, and population” section (Section 2.1), this is an observational study with a cross-sectional design. Data were collected at a single point in time for all participants, which allows for the investigation of associations between variables at that specific moment. In response to your suggestion, we have reworded the first sentence of Section 2.1 to explicitly emphasize its observational and cross-sectional nature, as shown below.
“2.1. Study Design, Setting, and Population
This cross-sectional, population-based epidemiological study was conducted following a census approach and adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [14]. Data collection involved the complete enumeration of older adults residing in the urban area of Aiquara, a municipality in the South-Central territory of Bahia state, Brazil. All participants were enrolled through the Family Health Strategy registry, Brazil's primary healthcare initiative operating under the Unified Health System, ensuring comprehensive municipal coverage [15].
Aiquara has 4,447 residents and a Human Development Index of 0.583. Among Bahia's 417 municipalities, Aiquara ranks 410th by
population size, representing a small urban environment conducive to comprehensive epidemiological assessment [16].”

2.3. How confounders (comorbidities, baseline activity levels etc.) were controlled?
Response: Dear Reviewer, thank you for your question regarding the handling of potential confounding factors. We addressed confounding through multivariate analysis using Poisson regression with robust variance estimation, as described in the Statistical Analysis section (Section 2.8). A comprehensive set of socioeconomic, behavioral, and health-related variables was considered as adjustment variables (listed in Section 2.7). Variables that remained significant at P ≤ 0.10 in the backward selection process were included in the final adjusted models for both dynapenic abdominal obesity and dynapenic obesity. The specific variables included in each final model are provided in the footnotes to Table 2. As our study employed a cross-sectional design, the concept of “baseline activity levels” is not applicable; instead, current physical activity levels and exposure to sedentary behavior were our primary independent variables, and other behavioral factors were adjusted for, as listed in Section 2.7. Additionally, in the Results section (Section 3), we reworded the paragraph presenting the adjusted associations to explicitly state that potential confounders were accounted for.
“2.7. Adjustment Variables (Covariables)
Multivariate model adjustment included the following variables:
 Socioeconomic: age (continuous, in years), sex (male or female), educational attainment (formal schooling: yes or no), and monthly income (≤ 1 minimum wage or > 1 minimum wage).

 Behavioral: tobacco use (current user: yes or no), alcohol consumption (current consumer: yes or no), fruit, vegetable, or legume intake (≥ 2 times/day: yes or no), dairy product (e.g., milk, cheese) consumption (daily: yes or no), and protein source (e.g., eggs, beans, lentils, soy) intake (weekly: yes or no).

 Health-related: self-reported physician diagnosis of hypertension (yes or no), self-reported physician diagnosis of diabetes mellitus (yes or no), and occurrence of fall episodes in the 12 months preceding data collection (yes or no).
2.8. Statistical Analysis
Descriptive analysis of participant characteristics was performed by calculating absolute and relative frequencies for categorical variables, and means and standard deviations for continuous variables. The response rate for each variable was also determined [31].
To assess the combined association of PA level and SB exposure with DAO and DO, Poisson regression with robust variance estimation was
employed. This approach allowed for the calculation of Prevalence Ratios (PR) and their respective 95% Confidence Intervals (CI) [32].
For the construction of the multivariate models, a backward stepwise elimination method was used. All adjustment variables listed in section 2.7 were initially included in the model. Variables were then sequentially removed based on the highest p-values (Wald test), with only those variables demonstrating a P-value ≤ 0.10 retained in the final models [33]. Data analyses were conducted using IBM SPSS Statistics for Windows, Version 21.0 (IBM Corp., Armonk, NY, USA). A significance level of 5% (P≤ 0.05) was adopted for all inferential analyses.”
Results:
“After controlling for potential confounding socioeconomic, behavioral, and health-related variables, the combined association of PA and SB levels with DAO and DO was evaluated. The adjusted analysis revealed that, compared to participants who were sufficiently active with low SB exposure (G1), those classified as insufficiently active with high SB exposure (G4) had 5.54 times the prevalence of DAO (PR: 5.54, 95% CI: 1.91–16.03) and 6.54 times the prevalence of DO (PR: 6.54, 95% CI: 1.68–36.66). These findings, along with results for other PA/SB combination groups, are presented in Table 2.”

2.4. You should integrate graphs to show how adiposity, strength, and activity change over time.
Response: Dear Reviewer, thank you for your valuable suggestion. We agree that visualizing changes in adiposity, strength, and physical activity over time would greatly enhance the understanding of these relationships. However, as noted previously and detailed in Section 2.1, our study employed a cross-sectional design. All variables were measured simultaneously at a single point in time for each participant. Consequently, we do not have longitudinal data to assess or illustrate changes in these variables over time. Such analyses would require a prospective or longitudinal study design.

2.5. Address whether responses differ by gender, baseline fitness, or other demographics and discuss consistency or discrepancies with other longitudinal studies.
Response: Dear Reviewer, thank you for your comment. As described in the Results section (Section 3) and Table 1, we provide descriptive characteristics of the study population, including sex and other demographic variables, highlighting differences in the prevalence of outcomes and characteristics between groups. In our multivariate analyses
(detailed in Sections 2.7 and 2.8 and in the footnotes of Table 2), we included gender, age, income, and other relevant socioeconomic and behavioral variables as adjustment factors. This approach controls for the potential confounding effects of these variables on the association between PA/SB groups and outcomes. Although we did not perform formal interaction tests (such as assessing whether the association between PA/SB groups and outcomes differs by gender), adjusting for these variables allows us to estimate associations independently of their main effects. The concept of "baseline physical fitness" is not directly applicable, given our cross-sectional design. Because our study is cross-sectional, we are unable to compare changes over time as in longitudinal studies. Nevertheless, in the Discussion section (Section 4), we compare the associations identified in our study (e.g., the higher likelihood of OAD/OD in participants with insufficient PA and high SB) with findings from the existing literature, including those from longitudinal studies and systematic reviews. This comparison focuses on the consistency or discrepancy of our observed associations between physical activity, sedentary behavior, and composite outcomes, rather than on temporal changes.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

This study was conducted to the combination of insufficient physical activity and sedentary behavior associated with dynapenic abdominal obesity and dynapenic obesity in older adults. This manuscript has scientific and novel and this was good topic from obesity in older adults.

 

The abbreviation “PA” for “physical activity” is widely recognized within the fields of public health and exercise science. However, in multidisciplinary journals such as Obesities (MDPI), which reach broader clinical and academic audiences, the abbreviation may not be as universally familiar. It could potentially lead to ambiguity (e.g., with terms such as “physician assistant,” “pulmonary artery,” and Posteroanterior).

 

As “physical activity; sedentary behavior, dynapenic abdominal obesity, dynapenic obesity”, appears very frequently throughout the manuscript, retaining the abbreviation after a clear initial definition is acceptable. However, if readability and clarity are priorities, and space constraints are not a major concern, consider using the full term throughout. This can enhance accessibility, especially for readers outside the immediate field.

 

Abstract

Line 50-54: The ‘5.54-fold, 6.54-fold’ was not good academic express. If it is possible, I recommend that this manuscript should be edited by an English professional editor for more readable. There are several grammatical errors.

 

Introduction

Please could you add backgrounds about the relationship among physical activity, sedentary behavior, dynapenic abdominal obesity, and dynapenic obesity. The introduction section was too short. It should be added over 5 paragraphs in Introduction section.

 

Method

Well-written

 

Results

In Table 2, it should be changed from ‘,’ to ‘.’ in whole results. For example. ‘4,66 (1,16-18,64)’ to ‘4.66 (1.16-18.64)’.

 

Discussion: Well-written

You should add more limitations and applications from this study.

 

Moreover, the references numbers were repeated numbers in Reference section. You should revised it. For example,

1. 1 - World Health Organization
2. 2 - Santos, L.;

 

Furthermore, checking by the iThenticate system, the plagiarism rate was 41% (quotes included and bibliography excluded). I believe that it is not acceptable plagiarism rate. Please reduce the plagiarism rate under 15%.

Comments for author File: Comments.pdf

Author Response

3. Reviewer 3 - Comments to the Author
3.1. This study was conducted to the combination of insufficient physical activity and sedentary behavior associated with dynapenic abdominal obesity and dynapenic obesity in older adults. This manuscript has scientific and novel and this was good topic from obesity in older adults.
Response: Dear Reviewer, we sincerely appreciate your encouraging and positive feedback regarding the scientific value, novelty, and relevance of our study. We are very pleased and honored that these aspects have been recognized.

3.2. The abbreviation “PA” for “physical activity” is widely recognized... However, in multidisciplinary journals... the abbreviation may not be as universally familiar... As “physical activity; sedentary behavior, dynapenic abdominal obesity, dynapenic obesity”, appears very frequently... retaining the abbreviation after a clear initial definition is acceptable... consider using the full term throughout.
Response: Dear Reviewer, thank you for raising the important issue of potential ambiguity with abbreviations in a multidisciplinary journal. While "Physical Activity (PA)" and "Sedentary Behavior (SB)" are standard terms within exercise science and public health, we appreciate the need for clarity for a broader audience. Given the frequent use of these terms—as well as "Abdominal Dynapenic Obesity (OAD)" and "Dynapenic Obesity (DO)"—throughout the manuscript, defining each abbreviation at its first mention and subsequently using only the abbreviation follows accepted practice for clarity and conciseness. This approach prevents excessive repetition of lengthy terms while maintaining readability. We have carefully reviewed the manuscript to ensure that all key abbreviations (PA, SB, OAD, DO) are clearly defined at their first appearance in both the Abstract and Introduction. Thereafter, only the abbreviations are used. We believe this approach effectively balances clarity for a multidisciplinary readership with academic conciseness, as you suggested is appropriate for frequently used terms.

3.3. Abstract Line 50-54: The ‘5.54-fold, 6.54-fold’ was not good academic express... I recommend that this manuscript should be edited by an English professional editor for more readable. There are several grammatical errors.
Response: Dear Reviewer, thank you for your specific feedback regarding academic expression and the overall quality of the English language. We fully agree that clear and precise language is fundamental to effective scientific communication. In response, we have subjected the entire manuscript to a thorough review and editing by a professional, native English-speaking reviewer with experience in scientific writing. This process was aimed at enhancing readability, correcting grammatical errors, and refining academic phrasing throughout the text—including in the presentation of results in the Abstract—to ensure both clarity and appropriateness.
Abstract: Objective: To investigate the association between combined physical activity (PA) levels and sedentary behavior (SB) with dynapenic abdominal obesity (DAO) and dynapenic obesity (DO) in older adults. Methods: This cross-sectional, population-based epidemiological study included 207 community-dwelling older adults (58.90% women). PA and SB were assessed using the International Physical Activity Questionnaire. Participants were categorized into four groups: G1) sufficiently active and low SB; G2) sufficiently active and high SB; G3) insufficiently active and low SB; and G4) insufficiently active and high SB. DAO and DO were defined as the coexistence of dynapenia with abdominal and general obesity, respectively. Prevalence ratios (PR) and 95% confidence intervals(CI) were estimated using Poisson regression with robust variance. Results: The prevalence of DAO was 11.10% and DO was 6.80%. In the adjusted analysis, participants classified as insufficiently active with high SB (G4) had 5.54 times the prevalence of DAO (PR: 5.54, 95% CI: 1.91–16.03) and 6.54 times the prevalence of DO (PR: 6.54, 95% CI: 1.68–36.66) compared to the reference group (G1) (sufficiently active and low SB). Conclusion: Insufficient PA combined with high SB was positively associated with both DAO and DO in the studied population of older adults.
Keywords: motor activity; aging; nutritional status; sedentary lifestyle; muscle strength

3.4. Introduction Please could you add backgrounds about the relationship among physical activity, sedentary behavior, dynapenic abdominal obesity, and dynapenic obesity. The introduction section was too short. It should be added over 5 paragraphs in Introduction section.
Response: Dear Reviewer, thank you for your careful and attentive reading of our manuscript. As noted, there is a limited body of literature directly addressing the relationship between physical activity, sedentary behavior, adolescent dynapenic obesity, and dynapenic obesity, which constrained the expansion of our introduction on this specific topic. However, we have revised the introduction to explicitly highlight this gap in the literature. Furthermore, in the Discussion section, we incorporate results from previous studies addressing the independent associations of these exposures with the outcomes, provide physiological explanations for our findings, discuss clinical applicability, and outline perspectives for future research.

3.5. Method: Well-written
Response: Dear Reviewer, thank you for your positive feedback on the Methods section. We are pleased that its clarity and quality have been recognized. We fully agree that a well-described methodology is essential for both the reproducibility and understanding of the study.

3.6. Results In Table 2, it should be changed from ‘,’ to ‘.’ in whole results. For example. ‘4,66 (1,16-18,64)’ to ‘4.66 (1.16-18.64)’.
Response: Dear Reviewer, thank you for your careful reading. We would like to inform you that Table 2 has been corrected as requested.

3.7. Discussion: Well-written. You should add more limitations and applications from this study.
Response: Dear Reviewer, thank you for your positive assessment of the Discussion section and for your constructive suggestion to further elaborate on the study’s limitations and applications. In response to this comment (which was raised in the original submission), we have expanded the Discussion section in the revised manuscript. We now provide a more detailed discussion of the study’s limitations, offering a comprehensive overview of its constraints. Additionally, we have enhanced the discussion of the potential applications and practical implications of our findings, including suggestions on how these results can inform clinical practice and public health strategies, as well as highlighting key avenues for future research.
”Despite its valuable contributions, this study has limitations that should be acknowledged when interpreting the findings. First, PA and SB were evaluated using a self-report questionnaire (IPAQ). While the IPAQ is a widely used instrument in epidemiological studies, it provides an indirect measure of these behaviors and is subject to potential recall and social desirability biases. Furthermore, it primarily captures total time spent in different intensity levels and does not fully account for sedentary time patterns, such as the frequency and duration of breaks in sedentary time. Second, the study population consisted of older adults residing in a specific small municipality in Northeastern Brazil. Although the census-based approach allowed for a comprehensive investigation within this context, the demographic, socioeconomic, and cultural characteristics of this population may limit the direct generalizability of our findings to older adults in significantly different geographical, socioeconomic, or healthcare access settings. However, these results are likely relevant for municipalities with similar profiles.
Further investigation into how specific local socio-cultural, economic, or environmental characteristics (e.g., access to health services, predominant cultural norms related to PA, or aspects of the built environment) might modulate these associations in diverse settings would enhance the applicability of these findings. Finally, despite controlling for several important potential confounding variables, the possibility of residual confounding by unmeasured factors (e.g., detailed dietary intake, specific chronic disease severity or duration, lifetime PA/SB trajectories) cannot be entirely excluded.
Notwithstanding these limitations, the present study also possesses notable strengths. One such strength is the use of the MMSE as a criterion to exclude older adults with cognitive impairment, thereby aiming to minimize potential recall bias in the self-reported measures. Another strength lies in the assessment of muscle strength through HGS, a method considered a gold standard for evaluating muscle weakness in older adults [39]. The census-based recruitment approach adopted in this
research is also noteworthy, as this strategy enabled the investigation of associations between insufficient PA combined with high SB exposure and DAO and DO in a population of older adults living in a small-sized municipality in an understudied region of Northeastern Brazil.
The findings of this research, demonstrating a strong association between the combination of insufficient PA and high SB exposure and a substantially higher prevalence of DAO and DO in older adults, carry significant practical implications for public health and clinical practice. While traditional interventions often prioritize increasing PA, our results highlight the critical need for dual approaches that simultaneously promote increased activity levels and a substantial reduction in time spent sedentary. Health professionals, particularly those working in primary care settings and contexts with limited resources, can utilize validated questionnaires, such as the IPAQ (employed in this study), to screen older adults for both PA levels and sedentary time. Identifying individuals who present this unfavorable combination of behaviors (insufficient PA and high SB) allows for targeting more specific and potentially more effective interventions.
Public health policies and health promotion programs aimed at the older adult population should, therefore, incorporate messaging and strategies that emphasize the importance of 'moving more and sitting less' throughout the day, extending beyond structured exercise sessions alone. Tailored, combined interventions, which might include community programs promoting both regular exercise (incorporating strength training appropriate for older adults) and practical strategies to reduce and interrupt daily sitting time (such as educational campaigns on the benefits of regular movement breaks and improvements in community walkability), could be instrumental in the prevention and management of dynapenic obesity, which represents a considerable health challenge in older populations, especially in municipalities with socioeconomic and healthcare access characteristics similar to Aiquara, Bahia, Brazil. Understanding these associations in such contexts provides a foundation for developing localized, impactful health initiatives.
Collectively, the findings of this research suggest etiological hypotheses regarding the influence of combined insufficient PA and high SB exposure on DAO and DO in older adults. These findings may provide a robust foundation for future epidemiological research. Longitudinal studies, such as prospective cohorts, are crucial to more definitively establish temporal relationships and the magnitude of risk. Such studies should ideally incorporate objective measures of PA and SB (e.g., accelerometers) to overcome self-report limitations and better characterize activity and sedentary patterns (including breaks in sedentary time). Furthermore, future research could also explore the efficacy of multifaceted interventions designed to mitigate these combined risks in older populations.”

3.8. Moreover, the references numbers were repeated numbers in Reference section. You should revised it. For example, 1. 1 - World Health Organization 2. 2 - Santos, L.;
Response: Dear Reviewer, thank you for your careful reading and attention to detail. We would like to inform you that the references have been corrected as requested.

3.9. Furthermore, checking by the iThenticate system, the plagiarism rate was 41% (quotes included and bibliography excluded). I believe that it is not acceptable plagiarism rate. Please reduce the plagiarism rate under 15%.
Response: Dear Reviewer, thank you for performing the similarity check and informing us of the initial rate of 41%. We fully agree that this percentage exceeds the acceptable standards for scientific publication. In response, we have carefully reviewed the entire manuscript and conducted a comprehensive rewording of substantial portions of the text to significantly reduce the similarity score and ensure proper citation of all sources. Our intent was to present the results and background information in our own words while accurately reflecting the foundational literature. We are confident that the revised manuscript now adheres to ethical standards and will meet the originality requirements expected by the journal. 

Reviewer 4 Report

Comments and Suggestions for Authors

This study aimed to investigate the association between PA level combined with SB exposure and DAO and DO in older adults. It is a study with a correct methodology, well written and with interesting conclusions.

Comments on the Quality of English Language

This study aimed to investigate the association between PA level combined with SB exposure and DAO and DO in older adults. It is a study with a correct methodology, well written and with interesting conclusions.

Author Response

4. Reviewer 4 - Comments to the Author 4.1. This study aimed to investigate the association between PA level combined with SB exposure and DAO and DO in older adults. It is a study with a correct methodology, well written and with interesting conclusions.
Response: Dear Reviewer, we are very grateful and honored by your positive evaluation of our manuscript. We sincerely appreciate your recognition of the study’s clear aim, sound methodology, well-written presentation, and interesting insights. Such encouraging feedback is highly motivating and reinforces our commitment to conducting high-quality research.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for your revision. I am satisfied with the revised manuscript. 

Reviewer 3 Report

Comments and Suggestions for Authors

The authors have extensively improved the quality of the manuscript by addressing the reviewers' comments and it can now be accepted for publication.