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. 2020 Jun 2;15(6):e0233565. doi: 10.1371/journal.pone.0233565

Development of an elderly lifestyle profile: A Delphi survey of multidisciplinary health-care experts

Kang-Hyun Park 1,¤a,‡, Ji-Hyuk Park 2,¤b,*
Editor: Gianluigi Forloni3
PMCID: PMC7266339  PMID: 32484817

Abstract

Objective

Lifestyle is considered as a key factor that affects one’s health and quality of life, and it has become the focus of increasing research interest worldwide. Research has shown that lifestyle is an important health determinant in preventive health care. However, lifestyle is a multifaceted construct and there is limited evidence regarding lifestyle assessment, which evaluates individuals’ multi-domain lifestyle factors. This study developed evaluation items for measuring the multifaceted lifestyle profile of community-dwelling older adult to prevent chronic disease and improve their health and quality of life.

Methods

Opinions from 21 experts with experience in older adults and lifestyle research were collected from December 2019 to January 2020. Three Delphi surveys were carried out, based on previous research. The first survey gathered opinions using a mix of open- and closed-ended questions regarding items of the older adults’ multifaceted lifestyle profile. The second was conducted after adding and modifying several items based on the first Delphi survey. In the third survey, after the results of the second one were presented to the expert panels, final opinions from the experts were converged.

Results

In total, 59 items were selected as the first Delphi results; 62 items were selected as the second results after adding and modifying the values below a content validity ratio of .42; and 62 items were selected as the third Delphi results. The average content validity ratio of the final Delphi survey was .92, the stability was .18, and the consensus was .80, which were all high.

Conclusions

This study verified the content validity of the evaluation items for community-dwelling older adults’ multifaceted lifestyle profile. In the future, it is expected that after verifying the validity and reliability, this will be used as a standardized assessment tool in clinical environments.

Introduction

According to World Population Prospects 2019 [1], there were 703 million people aged 65 years or over in the world in 2019. The number of older adults is projected to double to 1.5 billion by 2050. Population aging is a human success story; however, the increasing longevity tends to increase the financial burden on each country [1]. As populations age, it is essential to ensure continued and equitable access to disease prevention, treatment, and rehabilitation during all stages of life. Healthy aging is more than just the absence of disease; it also entails the maintenance of functional ability throughout the lifespan [2]. Therefore, health and long-term care systems need to be aligned to meet the needs of aging populations by providing age-appropriate lifestyle interventions based on accurate lifestyle profiling.

Occupational therapy is focused on a preventive approach that considers individuals’ different lifestyle factors and daily routines that are related to health and quality of life [3]. Previous research demonstrated that lifestyle redesign programs and the modification of lifestyle factors have been successful in promoting functional capacities and well-being among community-dwelling older adults [4] [5] [6]. Yet, the challenge of multifaceted lifestyle profiling of the older adults remains [7] [8]. Only a few measurements evaluate one’s health-related lifestyle; these tend to only include dietary factors, physical exercise, smoking, and/or drinking habits [9]. While lifestyles are important to improving the health and well-being of older adults, there has been little specific measurement of individuals ‘multifaceted lifestyle.

Lifestyle is considered a key factor that affects one’s health and quality of life, and it has become the focus of increasing research interest worldwide [10]. According to the World Health Organization, approximately 60% of an individual’s health-related quality of life depends on their lifestyle [2]. Moreover, recent evidence from lifestyle research on older adults demonstrated that a healthy lifestyle reduces the incidence of major chronic diseases such as diabetes and heart disease, as well as disability and mortality rates [11] [12] [13] [14]. Research also shows that lifestyle is an important health determinant in preventive health care. Although there is copious evidence on lifestyle interventions, the existing lifestyle research focuses on diet, physical activity, and unhealthy habits such as drinking and smoking as components and indicators of lifestyle [7]. However, lifestyle is a multifaceted construct. According to a review of the literature [4], a comprehensive definition of lifestyle for older adults mentions how a person spends their time and money, which represents an older adult’s values and personality. A review of the literature further identified a need to address this issue, as there are few specific measurements to assess a older adult’s lifestyle.

The goal of the present research was to develop a multifaceted lifestyle profile for older adults, agreed upon by multidisciplinary health-care experts including occupational therapists, physiotherapists, nutritionists, doctors, nurses, and social workers, in order to improve the validity of the profile. The intended use of this profile is as a screening tool to allow the quick identification of older adults who have unhealthy lifestyles and who need a more in-depth assessment to determine their fitness to live in the community independently.

Methods

Study design

We used a modified Delphi survey technique, a methodology commonly used to obtain a group consensus among “experts” through a series of structured open and closed questions [15] [16]. Ethics approval was granted by Yonsei University (YUWIRB-1041849-201901-BM-012-01).

Participants

We aimed to recruit health professionals deemed experts in the lifestyles and health of the older adults. For this, the researchers invited health professionals who had completed a graduate master’s degree or who had experience in relevant areas for over five years.

To enhance the diversity of the panelists’ expertise, we also targeted professionals from South Korea with recognized expertise in the fields of older adults’ lifestyles and/or health-care management for older adults within the scope of occupational therapy, physiotherapy, nutrition, social welfare, and preventive medicine. The eligibility criteria were to (a) be able to complete three rounds of the Delphi survey within a two-month timeframe, (b) be competent in using a computer, and (c) have access to the Internet and email.

Informed consent was obtained for the Delphi survey. Potential participants were sent an invitation email containing a letter introducing the survey and written consent form regarding the research. The participants checked a consent tick box on the first page of the survey. Participants submitted the informed written consent through email. Participants had the option to not complete the survey during any point in the process. To compensate them for their time, all participants received a $50 gift card after completing all rounds of the survey.

Delphi method procedures

After obtaining their consent, sociodemographic information was collected from the respondents. Participants were asked to read about the concept of multifaceted lifestyle components that were developed for creating a lifestyle profile of older adults in the first page of the survey questionnaire attached to an email (S1 Appendix in S1 Data). In the first page, physical activity, nutrition and activity participation are described as key domains of lifestyle based on the literature review and previous study [9]. Participants were then shown the next page which was consisted of 62 questions: 19 questions in the “physical activity” domain, 21 in the “activity participation” domain, and 22 in the “nutrition” domain. These items were developed by the researchers in accordance with our previous studies [4] [9] [17].

The Delphi survey consisted of three rounds (Fig 1). After completing the initial step, the panel participants were e-mailed an invitation to activate the round 1 questionnaire. The research team provided information regarding the study and received informed consent from all participants on the expert panel before starting the study. The participants were allowed to start the round 1, 2, and 3 questionnaire, which was delivered via email. The surveys for each round were available for two weeks, and a reminder was sent one day after the due date to participants who had not responded in order to maximize the response rate.

Fig 1. Research process.

Fig 1

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Round 1

The round 1 survey consisted of 59 closed-ended questions and 3 open-ended questions grouped into 3 themes. The survey was developed with open and closed questions to accommodate expert opinions. Participants were encouraged to add any recommendations or opinions regarding the questionnaire. The round 1of the survey required about 30 to 40 minutes to complete.

Round 2

The round 2 survey was developed based on the participants’ responses in round 1. The round 2 survey consisted of 62 closed-ended questions grouped into 3 categories (physical activities, activity participation, and nutrition). The participants received the survey via e-mail and were required to score the relevance of each proposed element using a four-point Likert-type scale (strongly relevant, relevant, not relevant, or strongly irrelevant). A neutral middle point was not included to force participants to provide their obvious opinions (Table 1). In round 2, three items were added from the round 1 items and these items were composed and grouped intro 3 categories.

Table 1. Example question asked to assess the relevance of each element in a particular category.

Category 1: Physical activity in your lifestyle
Items Relevance
Participation in aerobic exercise Strongly irrelevant 1 2 3 4 Strongly relevant
Participation in anaerobic exercise Strongly irrelevant 1 2 3 4 Strongly relevant
Participation in low-intensity exercise Strongly irrelevant 1 2 3 4 Strongly relevant
Participation in moderate-intensity exercise Strongly irrelevant 1 2 3 4 Strongly relevant
Participation in high-intensity exercise Strongly irrelevant 1 2 3 4 Strongly relevant
Participation in walking exercise Strongly irrelevant 1 2 3 4 Strongly relevant
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Round 3

Round 3 modified four questions and no questions from the second round were excluded. For 62 items, 80% agreement was reached. In the third round, we required the participants to rate the relevance of each item using a four-point Likert-type scale ranging from 1 (strongly irrelevant) to 4 (strongly relevant). The level of consensus was set to 80% of respondents indicating agreement [18] [20].

Data analysis

The round 1 result was subjected to a content analysis to identify and classify common elements in the overall opinion of the expert panel. We performed categorization by adding sub-items and modifying unclear expressions. In order to analyze the round 2 and 3 results, we calculated content validity ratios (CVRs). The minimum CVR was determined by the number of experts participating in each round [19]. According to the criteria, the CVR values of all items were set to 0.42 for 21 panel experts in rounds 2 and 3. The stability, which means the panel’s agreement on each item, was analyzed by the coefficient of variation divided by the arithmetic mean of the standard deviation of each item. If the coefficient of variation is less than 0.5, no further Delphi investigation is required, and if it is 0.5–0.8, it is relatively stable [20]. Regarding consensus, a higher consensus score demonstrated a higher level of agreement between participants [20].

Results

Demographics of the panel experts

We sent out a total of 30 invitations to potential participants. Of these, 21 participants gave their written consent to participate. All of 21 experts who participate in this study completed the round 1, 2, and 3 survey. There was no one who drop out the survey in the three steps. The characteristics of the final sample (n = 21) are presented in Table 2. Thirteen participants (62%) were female. Eighteen participants (86%) had over eight years’ experience in their professional area. The panel consisted of experts from various health-related professions, such as occupational therapists, nutritionists, social workers, physiotherapists, general practitioners, nurses, and researchers.

Table 2. Demographic characteristics of the respondents (n = 21).

Round 1 N (%) Round 2 N (%) Round 3 N (%)
Sample size 21 21 21
Response rate 100% 100% 100%
Gender Male 8 (38%) 8 (38%) 8 (38%)
Female 13 (62%) 13 (62%) 13 (62%)
Work experience 5–7 years 3 (14%) 3 (14%) 3 (14%)
8–10 years 9 (43%) 9 (43%) 9 (43%)
11 ≤ years 9 (43%) 9 (43%) 9 (43%)
Occupation (clinical/research/both) Occupational therapist 4 (19%) 4 (19%) 4 (19%)
Nutritionist 4 (19%) 4 (19%) 4 (19%)
Social worker 3 (14%) 3 (14%) 3 (14%)
Physiotherapist 4 (19%) 4 (19%) 4 (19%)
General practitioner 1 (5%) 1 (5%) 1 (5%)
Nurse 4 (19%) 4 (19%) 4 (19%)
Researcher 1 (5%) 1 (5%) 1 (5%)
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Results of round 1

The round 1 results are described in detail in Table 3. Twenty-one participants accessed the round 1survey and answered all questions. Round 1 was composed of 62 questions including 59 closed-ended questions and 3 open-ended questions in 3 groups. For the physical activity and activity participation categories, consensus was reached on all items. However, in terms of nutrition category, in order to measure the specific type of lifestyle of the older adults, the expert panel suggested three new items (nut intake, fruit intake, and dairy product intake). Thus, after completing the round 1, three new items were proposed.

Table 3. Categories and items of first Delphi results.

Category Items
Physical activity Aerobic physical exercise
Anoxic physical exercise
High-intensity physical exercise
Moderate-intensity physical exercise
Low-intensity physical activity
Walking
Activity participation Daily/Saturday/Sunday routine
Activities of daily living
Leisure activity
Social activity
Productive activity (paid work)
Education
Rest and sleep
Nutrition Rice or grains intake
Bread or flour intake
Potato or corn intake
Meat or chicken breast intake
Fish or tofu intake
Beans or egg intake
Sesame oil intake
Nuts intake*
Butter or margarine intake
Green vegetables or kim-chi intake
Fruit intake*
Seaweed intake
Dairy product intake*
Cheese intake
Anchovies intake
Water intake
Smoking habit
Alcohol intake
Protein intake for a week
Carbohydrate intake for a week
Fat intake for a week
Vitamin intake for a week
Mineral intake for a week
Water intake for a week
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* Newly added items in Round 1.

Results of round 2

The categories and items on the Delphi panel survey are listed in Table 4. In the physical activity, activity participation, and nutrition domains of the multifaceted older adults’ lifestyle, the CVR was 0.42 or higher and the content validity was verified for all items. The average value and CVR were the highest in “aerobic physical exercise,” “anoxic physical exercise,” “walking,” “leisure activities,” “social activities,” “education,” and “rest and sleep.” Contrariwise, the CVR for “low-intensity physical activity” was the lowest. However, the CVR scores were 0.61, 0.52, and 0.52 for the sub-themes of low-intensity activity; thus, these sub-items were not excluded. Thus, following the second round, all items and sub-items reached consensus. It is relevant to highlight that none of the initially proposed items were rejected during round 2.

Table 4. Contents of the multifaceted lifestyle in elderly profile in the round 2 survey.

Category Items Sub-items CVR* Mean** SD***
Physical activity Aerobic physical exercise How many days did you do aerobic exercise in the last week? 1 3.66 0.47
On average, how many times did you do aerobic exercise during the day? 0.90 3.58 0.64
Do you do as much as you want? 0.80 3.5 0.64
Anoxic physical exercise How many days did you do anoxic physical exercise in the last week? 0.90 3.5 0.64
On average, how many times did you do anoxic physical exercise during the day? 0.90 3.41 0.64
Do you do as much as you want? 0.71 3.16 0.68
High-intensity physical exercise How many days did you do high-intensity physical exercise in the last week? 0.80 3.58 0.64
On average, how many times did you do high-intensity physical exercise during the day? 0.71 3.5 0.76
Do you do as much as you want? 0.80 3.5 0.64
Moderate-intensity physical exercise How many days did you do moderate-intensity physical exercise in the last week? 0.80 3.5 0.64
On average, how many times did you do moderate-intensity physical exercise during the day? 0.80 3.41 0.64
Do you do as much as you want? 0.71 3.25 0.72
Low-intensity physical activity How many days did you do low-intensity physical activity in the last week? 0.61 3.33 0.74
On average, how many times did you do low-intensity physical activity during the day? 0.52 3.25 0.82
Do you do as much as you want? 0.52 3.08 0.75
Walking How many days did you go walking in the last week? 0.90 3.58 0.64
On average, how many times did you walk during the day? 1 3.75 0.43
Do you do as much as you want? 1 3.58 0.49
Activity participation Routine Please write out your daily routine 1 3.66 0.47
Please write out your Saturday routine 0.80 3.2 0.6
Please write out your Saturday routine 0.71 3.2 0.67
Activity of Daily Living (ADL) How many days did you participate in ADL in the last week? 0.90 3.58 0.64
On average, how many times did you do ADL per day? 0.90 3.5 0.64
Do you participate in ADL as much as you want? 1 3.66 0.47
Leisure activity How many days did you participate in leisure activities in the last week? 1 3.83 0.37
On average, how many times did you do leisure activities per day? 0.90 3.58 0.64
Do you participate in leisure activities as much as you want? 0.90 3.66 0.62
Social activity How many days did you participate in social activities in the last week? 1 3.66 0.47
On average, how much time did you spend on social activities per day? 0.90 3.5 0.64
Do you participate in social activities as much as you want? 0.90 3.58 0.64
Productive activity (paid work) How many days did you participate in productive activities in the last week? 0.90 3.58 0.64
On average, how much time did you spend on productive activities per day? 0.80 3.41 0.75
Do you participate in productive activities as much as you want? 0.80 3.5 0.64
Education How many days did you participate in education in the last week? 1 3.5 0.5
On average, how much time did you spend on education per day? 0.90 3.41 0.64
Do you participate in education as much as you want? 0.71 3.41 0.64
Rest and sleep On average, how much time do you spend asleep per day? 1 3.75 0.43
Do you sleep as much as you want? 0.90 3.66 0.62
Nutrition Protein Have you eaten rice or grain each day? 1.00 3.50 0.50
Have you eaten bread or flour each day? 1.00 3.42 0.49
Have you eaten potato or corn each day? 0.81 3.33 0.62
Carbohydrate Have you eaten meat or chicken breast each day? 0.90 3.42 0.64
Have you eaten fish or tofu each day? 0.90 3.42 0.64
Have you eaten beans or egg each day? 0.90 3.42 0.64
Fat Have you eaten sesame oil each day? 0.90 3.42 0.64
Have you eaten nuts each day? 1.00 3.50 0.50
Have you eaten butter or margarine each day? 0.71 3.25 0.60
Vitamins Have you eaten fruit each day? 0.90 3.50 0.50
Have you eaten seaweed each day? 0.90 3.42 0.64
Calcium Have you eaten dairy products each day? 0.71 3.25 0.83
Have you eaten anchovies each day? 1 3.33 0.47
Have you eaten cheese each day? 0.52 3.05 0.86
Minerals How much water do you drink per day? 0.81 3.42 0.76
Smoking How much do you smoke per week? 0.90 3.58 0.64
Alcohol How often do you drink alcohol on average per week? 1 3.67 0.47
How much do you consume when you drink alcohol each time? 1 3.67 0.47
Awareness of personal diet How much protein do you think you consumed in the last week? 0.81 3.17 0.90
How much carbohydrate do you think you consumed in the last week? 0.81 3.17 0.90
How much fat do you think you consumed in the last week? 0.81 3.08 0.86
How many vitamins do you think you consumed in the last week? 0.71 3.08 0.86
How many minerals do you think you consumed in the last week? 0.71 3.08 0.86
How much water do you think you consumed in the last week? 0.81 3.08 0.86
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*CVR = Content Validity Ratio of all sub-items;

**Mean = average values of each sub-items;

***SD = standard deviation of each sub-items.

Results of round 3

None of the 62 items analyzed had a minimum CVR of 0.42 or less (Table 5). As a result of round 3, compared with the second round, the relevance of the items was relatively high, and the panel’s responses resulted in relatively high convergence and agreement (Table 6).

Table 5. Contents of the multifaceted lifestyle in elderly profile in the round 3 survey.

Category Items Sub-items CVR* Mean** SD***
Physical activity Aerobic physical exercise How many days did you do aerobic exercise in the last week? 1 3.79 0.41
On average, how many times did you do aerobic exercise during the day? 1 3.63 0.48
Do you do as much as you want? 0.8 3.47 0.68
Anoxic physical exercise How many days did you do anoxic physical exercise in the last week? 0.9 3.42 0.59
On average, how many times did you do anoxic physical exercise during the day? 0.8 3.21 0.61
Do you do as much as you want? 0.7 3.21 0.69
High-intensity physical exercise How many days did you do high-intensity physical exercise in the last week? 0.8 3.58 0.67
On average, how many times did you do high-intensity physical exercise during the day? 0.8 3.42 0.67
Do you do as much as you want? 0.8 3.32 0.65
Moderate-intensity physical exercise How many days did you do moderate-intensity physical exercise in the last week? 0.9 3.47 0.60
On average, how many times did you do moderate-intensity physical exercise during the day? 0.8 3.26 0.64
Do you do as much as you want? 0.7 3.16 0.81
Low-intensity physical activity How many days did you do low-intensity physical activities in the last week? 0.7 3.37 0.74
On average, how many times did you do low-intensity physical activities during the day? 0.7 3.26 0.71
Do you do as much as you want? 0.7 3.21 0.69
Walking How many days did you go walking in the last week? 1 3.79 0.41
On average, how many times did you walk during the day? 0.9 3.68 0.57
Do you do as much as you want? 0.9 3.53 0.60
Activity participation Routine Please write out your daily routine 3.58 0.59 0.9
Please write out your Saturday routine 0.8 3.26 0.64
Please write out your Sunday routine 0.6 3.16 0.74
ADL How many days did you participate in ADL in the last week? 0.9 3.58 0.59
On average, how much time did you spend on ADL per day? 0.9 3.53 0.60
Do you participate in ADL as much as you want? 0.9 3.63 0.58
Leisure activity How many days did you participate in leisure activities in the last week? 1 3.79 0.41
On average, how much time did you spend on leisure activities per day? 0.9 3.53 0.60
Do you participate in leisure activities as much as you want? 0.9 3.63 0.58
Social activity How many days did you participate in social activities in the last week? 1 3.79 0.41
On average, how much time did you spend on social activities per day? 0.9 3.58 0.59
Do you participate in social activities as much as you want? 0.9 3.74 0.55
Productive activity (paid work) How many days did you participate in productive activities in the last week? 0.9 3.74 0.55
On average, how much time did you spend on productive activities per day? 0.8 3.47 0.68
Do you participate in productive activities as much as you want? 0.9 3.68 0.57
Education How many days did you participate in education in the last week? 0.8 3.42 0.67
On average, how much time do you spend on education per day? 0.9 3.47 0.60
Do you participate in education as much as you want? 0.9 3.47 0.60
Rest and sleep On average, how much time did you spend asleep per day? 0.9 3.74 0.55
Do you sleep as much as you want? 0.9 3.58 0.59
Nutrition Protein Have you eaten rice or grain each day? 1 3.58 0.49
Have you eaten bread or flour each day? 1 3.37 0.48
Have you eaten potato or corn each day? 0.9 3.26 0.55
Carbohydrate Have you eaten meat or chicken breast each day? 1 3.58 0.49
Have you eaten fish or tofu each day? 1 3.63 0.48
Have you eaten beans or egg each day? 1 3.63 0.48
Fat Have you eaten sesame oil each day? 1 3.26 0.44
Have you eaten nuts each day? 1 3.32 0.46
Have you eaten butter or margarine each day? 0.8 3.16 0.59
Vitamins Have you eaten fruit each day? 0.9 3.42 0.59
Have you eaten seaweed each day? 0.9 3.47 0.60
Calcium Have you eaten dairy products each day? 0.9 3.42 0.59
Have you eaten anchovies each day? 0.9 3.37 0.58
Have you eaten cheese each day? 0.6 3.00 0.79
Minerals How much water do you drink per day? 0.9 3.53 0.60
Smoking How much do you smoke per week? 1 3.58 0.49
Alcohol How often do you drink alcohol on average each week? 1 3.68 0.46
How much do you consume when you drink alcohol each time? 0.9 3.63 0.58
Awareness of personal diet How much protein do you think you consumed in the last week? 0.8 3.32 0.65
How much carbohydrate do you think you consumed in the last week? 0.8 3.32 0.65
How much fat do you think you consumed in the last week? 0.8 3.32 0.65
How many vitamins do you think you consumed in the last week? 0.8 3.26 0.64
How many minerals do you think you consumed in the last week? 0.8 3.26 0.64
How much water do you think you consumed in the last week? 0.9 3.37 0.58
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*CVR = Content Validity Ratio of all sub-items;

**Mean = average values of each sub-items;

***SD = standard deviation of each sub-items.

Table 6. Average opinions of the expert panel (n = 21).

M* SD** CVR*** Consensus
2nd Delphi 3.37 0.62 0.84 0.69
3rd Delphi 3.46 0.59 0.87 0.76
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*Mean = average values of all sub-items;

**SD = standard deviation of all sub-items;

***CVR = Content Validity Ratio of all sub-items.

Discussion

The need to develop a multifaceted lifestyle profile for the elderly population has been identified in the literature; such a profile will support the successful aging and health of the older adults. South Korea is getting older, and the prevalence of disease and disability among the aging population is growing [21]. Previous research shows that lifestyle factors affect successful aging; thus, it is possible to extend the health span of the older adults [22]. Moreover, a large body of research and theoretical literature demonstrates that physical, cognitive, and social functioning are key elements of successful aging and that a multifaceted lifestyle influences them [23] [24]. Therefore, the interest in and demand to evaluate the lifestyles of the older adults are increasing worldwide. However, a review of the literature and previous studies showed that there are limited resources regarding multifaceted lifestyle profile assessment specific to community-based practice for the older adults [9]. The Delphi method was appropriate for surveying experts on this topic. Applying this method, we uncovered multidisciplinary recommendations for assessing the lifestyles of the elderly. We will discuss our suggestions based on the consensus of the expert panel in the study.

Previous research has shown that many age-related decreases in physical and cognitive functioning can be explained in terms of lifestyle factors such as physical activity [25]. Moreover, most national and international physical activity guidelines and position statements recommend that elderly individuals participate in regular physical activity as a means of preventing disease, promoting health, and delaying functional loss [26]. According to the expert panel, we also found that physical activities such as “aerobic and anoxic exercise” and “high-, moderate-, and low-intensity activity” are crucial factors in assessing the lifestyles of the older adults. In particular, in comparison with the existing lifestyle assessments, which evaluate low-intensity physical activities or walking, physical activities of various intensities should be considered in order to provide recommendations on modifying the older adults’ lifestyles in the future. The literature illustrated that consistent participation in moderate physical activity appears necessary to optimize physical and mental health [27] [28]. Thus, it seems that various types of physical activity should be evaluated when we develop a multifaceted lifestyle profile for the elderly.

The pattern of activity participation in daily life is also an important factor. Research has demonstrated that active participation in social activities [29] [30] [31], leisure activities [32], or productive and educational activities [33] [34] is able to enhance cognitive functioning [35] [33], improve mental health [36], reduce functional disabilities [31], and delay mortality [37]. Although there is evidence that engagement in a variety of activities affects health outcomes, few studies have examined, including activity participation along with other lifestyle factors such as physical activity and nutrition … In this study, the expert panel agreed on the relevance and importance of measuring activity participation as one of the multifaceted lifestyle domains. Occupational balance has been shown to be related to health and well-being and it is a recurring crucial element in the occupational therapy literature as well as in health promotion [38] [39] [40]. Moreover, participation in various activities is associated with life satisfaction. Havighurst (1963) pointed out that people experience greater satisfaction with life by maintaining various activities and social roles as opposed to living a solitary lifestyle [41].

Older adults are particularly vulnerable to malnutrition [42]. As we get older, our bodies have different needs; thus, certain nutrients become especially vital for good health. Therefore, it is important for health professionals to investigate the elderly’s daily diet; amount of food consumed; and balance of major nutrients such as protein, carbohydrates, fat, vitamins, minerals, and water. Several experts suggested that the questions should be modified to provide more specific and elderly-friendly examples in each sub-item and we modified several sub-items in the nutrition part. The literature illustrates that eating a healthy, balanced diet is key for older people to have more active lives [43] [44]. Diets evolve over time, being affected by complex factors including social and economic elements that shape individual dietary patterns. The proportion of malnutrition in the elderly in South Korea decreased from 28.7% in 1998 to 1 in 6 people in 2015, but it is still very poor compared to other age groups. Thus, promoting healthy food consumption by the elderly requires the involvement of multiple sectors and stakeholders. In order to do that, detailed nutritional evaluations of people’s lifestyles are necessary.

This study proposed a multifaceted lifestyle profile for enhancing elderly health and quality of life. The main strengths of our study are its responses from a panel of multidisciplinary health professionals and its good response rates. However, some limitations also need to be recognized. This study analyzed only the content validity of the items in the multifaceted lifestyle profile by the expert panel. Therefore, validity and reliability studies should be conducted in the future. Finally, only health-care professionals from South Korea were invited to participate; thus, our panel of experts was not international. Hence, this research might only represent a limited viewpoint.

Conclusions

The present study used a modified Delphi method to develop an elderly lifestyle profile. The process resulted in a total of 62 items divided into 3 categories. This assessment can be useful in clarifying the elderly’s lifestyle and helping to identify individuals who require more in-depth lifestyle modification and related interventions. However, individual’s lifestyle tends to be affected by various environmental factors including geographic factor and cultural factor. Therefore, further research should be conducted with people who live in multiple ethno-geographic regions. Also, further research is now required to confirm the validity and reliability of this measurement.

Supporting information

S1 Data

(DOCX)

Click here for additional data file. (32KB, docx)

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

This work was supported by The Ministry of Education of the Republic of Korea and the National Research Foundation of Korea NRF-2018S1A3A2074904 to J-HP.

References

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Decision Letter 0

Gianluigi Forloni

25 Mar 2020

PONE-D-20-05504

Development of an elderly lifestyle profile: A Delphi survey of multidisciplinary health-care experts

PLOS ONE

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Partly

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Reviewer #1: Yes

Reviewer #2: I Don't Know

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors tried to answer an interesting research question about the lifestyle influence on aging quality , that is which factors must be considered very important among the various possible agents. They considered three areas (Physical activity, Activity participation, Nutrition ) and used a Delphi method to achieve the outcome, with open and closed questions proposed to a panel of 21 experts in three successive steps. Finally they proposed 62 items with a relatively high consensus from the experts. In general the method seems to be correctly implemented and the collected data support the conclusion. The areas and items derived largely from previous researches and meta-analysis by the same authors, published on peer review journals, but unfortunately in Korean not so accessible to most readers ( but there is a summary in English). Likewise many factors are strongly influenced by the ethno-geographical area like nutrition. The authors correctly reported these elements as limitations at the end of the discussion. In the conclusion I suggest indicating the need for studies that include multiple ethno-geographic areas.

Participants : are the 21 experts the same across the three steps of the Delphi consultation? does it mean that no one gave up participating in the three steps or that only those who participated to the end were included? It should be specified.

There are no comments on those who refused to participate (do they have different characteristics than the participants?)

are the participants partly the same as in the published preliminary study? if so it should be specified

Now some detailed comments:

98 “through a file attached to an email.” what is its content? is it explained in the next sentence?

109 “All open-ended

110 questions were included to ensure that the survey accommodated the opinions from the experts” : this sentence is not clear to me, it must be explained or rewritten.

126 “The

127 level of consensus was set to 80% of respondents indicating agreement [18]”. This statement is not supported by reference 18. The same for :

135 If the coefficient of variation is less than 0.5, no further Delphi investigation is

136 required, and if it is 0.5–0.8, it is relatively stable [18].

213 The literature illustrates that eating a healthy, balanced diet is key for older people to have more

214 active lives [43]. Are you sure you can't find a better reference for such a general and important statement? You mentioned one cross-sectional research on a limited number of Brazilians.

Table 4 & 5 : the title “mean” of the second column must be explained, as well as “ M” in table 6

References :

19 : this is the seminal paper from Lawshe, are you aware of the Wilson’s criticisms about it? F. Robert Wilson, Wei Pan & Donald A. Schumsky (2012) Recalculation of the Critical Values for Lawshe’s Content Validity Ratio, Measurement and Evaluation in Counseling and Development, 45:3, 197-210, DOI: 10.1177/0748175612440286

38 Erlandsson LK, Eklund M. Levels of complexity in patterns of daily occupations: Relationships to women’s : it must be completed

42 : the URL didn’t work. are you sure you have correctly reported it ?

I tried another WHO reference

World Health Organization Healthy Diet. [(accessed on 2020)]; Available online: https://www.who.int/news-room/fact- sheets/detail/healthy-diet.

Reviewer #2: Thank you for the opportunity to review this manuscript outlining the development of a lifestyle profile for older adults. This work has the potential to contribute to the development of a measurement tool to identify to older adults in South Korea who would benefit from a lifestyle modification intervention. While the manuscript is mostly well-written and organised, and is based on a sound review of the literature, I have some concerns with the methods and results. There are also minor concerns relating to the clarity of some sentences, and the terminology used for older adults. These are outlined below and if the authors are able to adequately address these issues the quality of the manuscript will be improved.

Major issues

1. METHODS

• P5, line 97: “… asked to read about the concept of multifaceted lifestyle components” – it would be helpful to the reader to have this information included as a supplementary file.

• P5, line 99: “ … an online document consisting of 65 items” – is this different to the information they were provided about the concept of multifaceted lifestyle components?

• P5, line 101: “A total of 65 items …” – this is repetitive of line 99. I suggest consolidating the information.

• P5, line 103: Figure 1 – Figure 1 outlines “Stage 1, 2, 3” and “First, Second and Third Delphi Survey”. However the text in the Methods uses “Round 1, 2, 3” and “first-round questionnaire” (line 104). It would be easier for the reader to follow if the Figure and the text used the same descriptive wording.

• P5, lines 110-113: “After finishing their part, the panel participants were e-mailed ……. before starting the study” – this information is already mentioned in the previous paragraph. Suggest consolidating it into the first paragraph of Methods as it provides a clear understanding of what participants were required to complete prior to the first survey/round 1.

• P6, line 120: Suggest the use of a different word to ‘valence’ as the meaning of this word in the sentence is ambiguous; maybe a simpler word that clearly describes what participants were forced to choose would be easier to read?

• P6, lines 123-124: This section is headed Round 3 and mentions that four questions were modified with no questions excluded from Round 2. However the next sentence then goes back to talking about what happened in Round 2 (three items modified and one added) – which is confusing to me and I wonder whether it would be better mentioned in the Round 2 section? I apologise if I am misunderstanding, but I find it difficult to follow.

• P7, line 133: “21 panels” – I think this should read 21 panel experts as 21 panels were not used in this study.

RESULTS

• P8, line 151: consensus was reached for all 18 physical activity domain items, but Table 1 includes only 6 physical activity items? It is not until the I got to Table 4 that it was clear that you were talking about sub-items of the 6 PA items. I think this could be more clearly explained to avoid confusing the reader.

• P10, Table 4: This table outlines the contents of the second Delphi survey and lists questions relating to 59 sub-items. However in the Methods (p6, line 117) the authors state that the 2nd survey consisted of 62 questions. This discrepancy needs to be addressed and clearly explained.

• P13, line 168: “none of the 62 items analysed” – Table 5 includes 60 questions (as one item was added from the second survey). The discrepancy between 62 and 60 items needs to be addressed, or more clearly explained.

• P16, Table 6: M, SD and CVR need to be spelled out in full within the table or the abbreviations included as a legend to the table.

Minor issues:

1. Terminology for ‘older adults’. The authors use different terms throughout the manuscript, including ‘older persons’, ‘older adults’ ‘elders’, ‘the elderly’. The generally accepted terms exclude ‘elders’ and include ‘older adults or individuals or people’. This may, however be different in different countries, including for South Korea. I suggest using the accepted appropriate terminology and using it consistently throughout the manuscript.

2. INTRODUCTION

The introduction is clearly and logically organised and well set within the current literature. A few minor suggestions may improve the readability:

• P3, lines 55-56: “Only a few measurements evaluate one’s health-related lifestyle. However, they tend to only include …” – the link between these two sentences is not clear and I suggest combining the sentences to improve the flow, e.g. only a few measurements evaluate one’s health-related lifestyle; these tend to only include ….:.

• P3, line 58: I think what the authors are trying to say is that there has been little specific measurement of individuals’ multifacted lifestyles? The way this sentence is currently written is confusing to me and relies on the reader knowing what the multifaceted ‘areas’ are. A description of multifaceted lifestyle is included in the following paragraph, but some clarity earlier in the introduction would be beneficial.

3. DISCUSSION AND CONCLUSION

The discussion is well organised and easy to follow. Some minor suggestions include:

• P17, line 190: “crucial factors in assessing the lifestyles …” – it should be clarified that this is according to the expert panel.

• P17, line 196: Suggested deleting the word ‘numerous’ and simply state that: research has demonstrated …

• P17, lines 200-201: “few studies have examined these factors in the elderly with other lifestyle factors” – are you trying to say that few studies have examined these factors combined with other lifestyle factors? If possible this needs to be more clearly stated.

• P.17, lines 202-203: “we were able to assess the life-balance” – you did not assess this, you assessed the opinions of experts and it would be clearer for the reader if you stated that clearly here.

4. ABSTRACT

• P.2, line 29: “… questions reconstructed regarding the evaluation items …” – this meaning of this sentence is not clear to me. I am not able to suggest changes, but it should be rewritten to convey its meaning more clearly.

**********

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Reviewer #1: Yes: Antonio Guaita

Reviewer #2: No

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PLoS One. 2020 Jun 2;15(6):e0233565. doi: 10.1371/journal.pone.0233565.r002

Author response to Decision Letter 0

28 Apr 2020

Dear Editor and reviewers,

We thank you and the reviewers for a thorough reading and constructive review of our manuscript and for the opportunity to revise and resubmit. We are pleased to submit the improved research article. We upload the 'response to reviewers' file. Please find our response to each point raised by academic editor and reviewers.

� Academic editor

Journal Requirements:

When submitting your revision, we need you to address these additional requirements: 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.plosone.org/attachments/PLOSOne_formatting_sample_main_body.pdf and http://www.plosone.org/attachments/PLOSOne_formatting_sample_title_authors_affiliations.pdf

To address the editor’s concern, the manuscript was modified in order to meet the PLOS ONE’s style. Based on the PLOS ONE style templets, we modified title, author, affiliations formatting. We hope that this formatting is appropriate for the PLOS ONE requirement.

2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed).

In page 4, we added details about participant consent. Informed consent was obtained for the Delphi survey. We sent email to potential participants including invitation letter which include information of the survey and written consent form. All participants submitted written consent form through email. We describe this process clearly in 94-97 lines.

3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information

In order to address this concern, we provided Delphi questionnaire in English and Korean version as supporting information. We hope that this material can help you to understand the research.

4. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

I updated my information, so I register my ORCID ID in Editorial manager. Please let me know, if any other issue regarding this.

� Reviewer #1:

The authors tried to answer an interesting research question about the lifestyle influence on aging quality, that is which factors must be considered very important among the various possible agents. They considered three areas (Physical activity, Activity participation, Nutrition) and used a Delphi method to achieve the outcome, with open and closed questions proposed to a panel of 21 experts in three successive steps. Finally, they proposed 62 items with a relatively high consensus from the experts. In general, the method seems to be correctly implemented and the collected data support the conclusion. The areas and items derived largely from previous researches and meta-analysis by the same authors, published on peer review journals, but unfortunately in Korean not so accessible to most readers (but there is a summary in English). Likewise many factors are strongly influenced by the ethno-geographical area like nutrition. The authors correctly reported these elements as limitations at the end of the discussion. In the conclusion I suggest indicating the need for studies that include multiple ethno-geographic areas.

Like your advice, we also deeply agree with that lifestyle tends to be affected by various environmental issues. Thus, we also mentioned it in the conclusion (you might check additional description in 236, 237, and 238) and we also are planning to conduct further study which include people who live in multiple ethno-geographic areas.

Participants : are the 21 experts the same across the three steps of the Delphi consultation? does it mean that no one gave up participating in the three steps or that only those who participated to the end were included? It should be specified.

There are no comments on those who refused to participate (do they have different characteristics than the participants?)

are the participants partly the same as in the published preliminary study? if so it should be specified

1) In the study, all of the 21 experts participated in the 1,2, and 3 round survey. Yes, there was no one to drop out in the three steps. In order to clear this point, we describe it in the demographic of the panel experts (line numbers are 148, and 149). When we conducted this research, we reminded people about this survey due date before one week, and encourage them to complete the survey until round 3. We thought that that is why we could obtain the all participants’ reply.

2) Initially, when we recruited professionals who participate in this study, we sent out a total of 30 invitations to potential participants. Among them, only 21 people sent the written consent form and they said that they want to participate in the study. Regarding people who refused to participate in our study, we did not send any other additional email. Thus, we could not obtain information regarding people who refused our survey. However, like you said, we also agree that it is important to know the reason and characteristics of people who refused the survey. Hence, if we conduct further study, we will investigate the different characteristics between participants and non-participants.

3) The participants are the same persons in the published preliminary study.

Now some detailed comments:

98 “through a file attached to an email.” what is its content? is it explained in the next sentence?

The file which we attached to an email is questionnaire. In this file, lifestyle factors such as physical activity, nutrition and activity participation were described as key domains of lifestyle briefly. This is because we want to give background information to participants regarding lifestyle elements which were developed by previous study. And then in the next page, a total of 65 items were included in the same questionnaire. We think that “a file” might make you and other readers confuse. Thus, we decide to change the sentence from the “through a file attacked to an email” to “through a survey questionnaire attached to an email” in order to be clear (in line number 104). Also, we describe more additional information regarding the survey questionnaire in line 104, 105,106.

109 “All open-ended

110 questions were included to ensure that the survey accommodated the opinions from the experts” : this sentence is not clear to me, it must be explained or rewritten.

In order to be clear, we change the sentence like following.

“The survey was developed with open and closed questions to accommodate expert opinions.” (line number

126 “The

127 level of consensus was set to 80% of respondents indicating agreement [18]”. This statement is not supported by reference 18. The same for :

135 If the coefficient of variation is less than 0.5, no further Delphi investigation is

136 required, and if it is 0.5–0.8, it is relatively stable [18].

We checked the reference and the sentence that you pointed out, you are right, there was a mistake to cite reference. The correct reference number was [20] which was describe about Delphi method. Thus we revised the reference number correctly from [18] to [20] (line numbers are 136 and 145)

213 The literature illustrates that eating a healthy, balanced diet is key for older people to have more

214 active lives [43]. Are you sure you can't find a better reference for such a general and important statement? You mentioned one cross-sectional research on a limited number of Brazilians.

As you recommended, we search again so as to find some better references. Thus, we find a reference which can support the sentence and add it (line number 225).

[44] de Groot, Lisette CPMG, Verheijden Marieke W, de Henauw, Stefaan, Schroll, Marianne, & van Staveren, Wija A. Lifestyle, nutritional status, health, and mortality in elderly people across Europe: a review of the longitudinal results of the SENECA study. The Journals of Gerontology, Series A . 2004; 59(12), 1277–12784. https://doi.org/10.1093/gerona/59.12.1277

Table 4 & 5 : the title “mean” of the second column must be explained, as well as “ M” in table 6

In the table 4 and 5, each sub-item’s mean was provided separately. However, in Table 6, mean values of all sub-items was provided. That is the mean in table 6 was the mean of 62 items. Participants scored whether each sub-item is relevant or not. At this time, the score consists of a 4-point Likert scale, and the average value of all sub-items is given in the table as “Mean”. We indicated the mean of the “Mean” at the bottom of the table.

References :

19 : this is the seminal paper from Lawshe, are you aware of the Wilson’s criticisms about it? F. Robert Wilson, Wei Pan & Donald A. Schumsky (2012) Recalculation of the Critical Values for Lawshe’s Content Validity Ratio, Measurement and Evaluation in Counseling and Development, 45:3, 197-210, DOI: 10.1177/0748175612440286

We appreciate for your useful information. Actually, we didn’t know that Wilson’s criticisms about Lawshe, thus, we read the paper. By reading this, we aware of this and if we conduct further study, we will consider it.

38 Erlandsson LK, Eklund M. Levels of complexity in patterns of daily occupations: Relationships to women’s : it must be completed

We apologized that it was our mistake. So, we revise the reference correctly.

38. Erlandsson LK, Eklund M. Level of complexity in patterns of daily occupations: Relationships to women’s well-being. Occup. Sci. 2006. 27-36. http://doi.org/10/1080/14427591.2006.9686568

42: the URL didn’t work. Are you sure you have correctly reported it?

I tried another WHO reference

World Health Organization Healthy Diet. [(accessed on 2020)]; Available online: https://www.who.int/news-room/fact-sheets/detail/healthy-diet.

When we tried to connect again, the URL worked. Like below page. Please tried again, and if you could not access the page, please let us know.

� Reviewer #2:

Thank you for the opportunity to review this manuscript outlining the development of a lifestyle profile for older adults. This work has the potential to contribute to the development of a measurement tool to identify to older adults in South Korea who would benefit from a lifestyle modification intervention. While the manuscript is mostly well-written and organised, and is based on a sound review of the literature, I have some concerns with the methods and results. There are also minor concerns relating to the clarity of some sentences, and the terminology used for older adults. These are outlined below and if the authors are able to adequately address these issues the quality of the manuscript will be improved.

Major issues

1. METHODS

• P5, line 97: “… asked to read about the concept of multifaceted lifestyle components” – it would be helpful to the reader to have this information included as a supplementary file.

In order to understand the reader, we provided a supplementary file (the file name is supplementary 2). This information regarding the concept for multifaceted lifestyle component was developed by our previous research (Park K, Han D, Park H, Ha S, Park. Pilot research for development of multi-faceted lifestyle profile components affecting health and quality of life: Delphi survey. Korean Journal of Occupational Therapy. 2019; 27(3): 105–120).

In order to make clear, we modified the sentence in the manuscript like follow (P5. line 104)

“Participants were asked to read about the concept of multifaceted lifestyle components that were developed for creating a lifestyle profile of elders through a file attached survey questionnaire attached to an email (S1 Appendix). In the survey questionnaire, physical activity, nutrition and activity participation are described as key domains of lifestyle based on the literature review and previous study.”

• P5, line 99: “ … an online document consisting of 65 items” – is this different to the information they were provided about the concept of multifaceted lifestyle components?

Yes, we sent a survey questionnaire which contain two part to the participants. First section in the survey questionnaire demonstrated about the concept of multifaceted lifestyle components that were developed for creating a lifestyle profile based on the previous research (Park et al., 2019). The aim of the first section was to help participants to understand lifestyle components. And second part was consisted of 65 items. Thus, there were two kind of different information included in a survey questionnaire. However, we also agreed that readers might be confused like you, thus, we will provide a survey questionnaire as a supplementary file.

• P5, line 101: “A total of 65 items …” – this is repetitive of line 99. I suggest consolidating the information.

In order to make clear the manuscript, we consolidated the line 99 and line 101 like follow:

“Participants were then shown the next page which was consisted of 65 items: 19 items in the “physical activity” domain, 21 in the “activity participation” domain, and 25 in the “nutrition” domain” (P5. Line 106-108).

• P5, line 103: Figure 1 – Figure 1 outlines “Stage 1, 2, 3” and “First, Second and Third Delphi Survey”. However, the text in the Methods uses “Round 1, 2, 3” and “first-round questionnaire” (line 104). It would be easier for the reader to follow if the Figure and the text used the same descriptive wording.

We deeply agreed with your opinion, thus we modified the figure 1 outline form “First, Second, and Third Delphi as well as we modified the manuscript (P5. Line 111).

• P5, lines 110-113: “After finishing their part, the panel participants were e-mailed ……. before starting the study” – this information is already mentioned in the previous paragraph. Suggest consolidating it into the first paragraph of Methods as it provides a clear understanding of what participants were required to complete prior to the first survey/round 1.

As your comment, there were some sentences which should be reorganized. So as to make the manuscript clearly, we consolidated the line 110-113 sentences to the “Delphi method procedures” paragraph (P5, line 110-115).

• P6, line 120: Suggest the use of a different word to ‘valence’ as the meaning of this word in the sentence is ambiguous; maybe a simpler word that clearly describes what participants were forced to choose would be easier to read?

We apologize for confused you. We looked into the sentence and we found that ‘valence’ was our mistake. Thus, we change the sentence like following:

“A neutral middle point was not included to force participants to provide their obvious opinions.” (P6, line 127)

• P6, lines 123-124: This section is headed Round 3 and mentions that four questions were modified with no questions excluded from Round 2. However, the next sentence then goes back to talking about what happened in Round 2 (three items modified and one added) – which is confusing to me and I wonder whether it would be better mentioned in the Round 2 section? I apologise if I am misunderstanding, but I find it difficult to follow.

We agreed that the sentences from line 123 to 124 could make the reader confused. Therefore, we re-writhed the paragraph. We moved the sentence which are taking about round 2 from the ‘Round 3’ section to the ‘Round 2’ section Thus, the final version is like follow:

“Round 2

The round 2 survey was developed based on the participants’ responses in the first round. The round 2 survey consisted of 59 closed-ended questions grouped into 3 categories (physical activities, activity participation, and nutrition). The participants received the survey via e-mail and were required to score the relevance of each proposed element using a four-point Likert-type scale (strongly relevant, relevant, not relevant, or strongly irrelevant). A neutral middle point was not included to force participants to provide their obvious opinions (Table 1). In round 2, three items were modified and one item was added. Finally, 62 items were composed and grouped into 3 categories

Table 1 is here

Round 3

Round 3 modified four questions and no questions from the second round were excluded. For 65 items, 80% agreement was reached. In the third round, we required the participants to rate the relevance of each item using a four-point Likert-type scale ranging from 1 (strongly irrelevant) to 4 (strongly relevant). The level of consensus was set to 80% of respondents indicating agreement [20]. “

• P7, line 133: “21 panels” – I think this should read 21 panel experts as 21 panels were not used in this study.

To further clarify the sentence, line 133 sentence was revised as follow.

“According to the criteria, the CVR values of all items were set to 0.42 for 21 panel experts in rounds 2 and 3.”

RESULTS

• P8, line 151: consensus was reached for all 18 physical activity domain items, but Table 1 includes only 6 physical activity items? It is not until the I got to Table 4 that it was clear that you were talking about sub-items of the 6 PA items. I think this could be more clearly explained to avoid confusing the reader.

Like your comment, we agreed that the sentence (line 151) could make the reader confused. As a result of discussing with co-author, we decided to the deleted the item numbers and modified the sentence like below.

“For the physical activity and activity participation categories, consensus was reached on all items”

• P10, Table 4: This table outlines the contents of the second Delphi survey and lists questions relating to 59 sub-items. However in the Methods (p6, line 117) the authors state that the 2nd survey consisted of 62 questions. This discrepancy needs to be addressed and clearly explained.

As you pointed out, there was some mistake as we described the results of round 1,2, and 3. Like you said, three sub-items were missing from the Table 4. (Please write out your Saturday routine, please write out your Sunday routine, and have you eaten cheese each day). We corrected Table 4 again(P.10). Thank you for your comment and we also sorry to confuse you.

• P13, line 168: “none of the 62 items analysed” – Table 5 includes 60 questions (as one item was added from the second survey). The discrepancy between 62 and 60 items needs to be addressed, or more clearly explained.

There was a similar mistake above, Thus, we looked at the Table 5, and corrected it. In order to prevent more confusing, we checked every number in the paper.

• P16, Table 6: M, SD and CVR need to be spelled out in full within the table or the abbreviations included as a legend to the table.

In order for the reader to understand the information in the table 6, we added the abbreviations of M, SD and CVR in the table 6.

Minor issues:

1. Terminology for ‘older adults’. The authors use different terms throughout the manuscript, including ‘older persons’, ‘older adults’ ‘elders’, ‘the elderly’. The generally accepted terms exclude ‘elders’ and include ‘older adults or individuals or people’. This may, however be different in different countries, including for South Korea. I suggest using the accepted appropriate terminology and using it consistently throughout the manuscript.

We also agreed with that using different terms for older adults would be able to make confuse the reader. Hence, we selected ‘older adults’ as an appropriate terminology and we used it consistently throughout the manuscript instead of ‘older persons’, ’elders’, ’the elderly’.

2. INTRODUCTION

The introduction is clearly and logically organised and well set within the current literature. A few minor suggestions may improve the readability:

• P3, lines 55-56: “Only a few measurements evaluate one’s health-related lifestyle. However, they tend to only include …” – the link between these two sentences is not clear and I suggest combining the sentences to improve the flow, e.g. only a few measurements evaluate one’s health-related lifestyle; these tend to only include ….:.

We are appreciated for your suggestion. As you suggested, we combined the sentences as follow.

“Only a few measurements evaluate one’s health-related lifestyle; these tend to only include dietary factors, physical exercise, smoking, and/or drinking habits.”

• P3, line 58: I think what the authors are trying to say is that there has been little specific measurement of individuals’ multifacted lifestyles? The way this sentence is currently written is confusing to me and relies on the reader knowing what the multifaceted ‘areas’ are. A description of multifaceted lifestyle is included in the following paragraph, but some clarity earlier in the introduction would be beneficial.

We also agreed that ‘areas’ could make the readers confuse thus, we changed the sentence as follow in order to be clear.

“While lifestyles are important to improving the health and well-being of older adults, there has been little specific measurement of individuals’ multifaceted lifestyles”

3. DISCUSSION AND CONCLUSION

The discussion is well organised and easy to follow. Some minor suggestions include:

• P17, line 190: “crucial factors in assessing the lifestyles …” – it should be clarified that this is according to the expert panel.

In order to be clarified the sentence, we modified it as below,

“According to the expert panel, we also found that physical activities such as “aerobic and anoxic exercise” and “high-, moderate-, and low-intensity activity” are crucial factors in assessing the lifestyles of the older adults.”

• P17, line 196: Suggested deleting the word ‘numerous’ and simply state that: research has demonstrated …

As your suggestion, we had made the sentence simpler by deleting the word ‘numerous’

“Research has demonstrated that active participation in social activities.”

• P17, lines 200-201: “few studies have examined these factors in the elderly with other lifestyle factors” – are you trying to say that few studies have examined these factors combined with other lifestyle factors? If possible this needs to be more clearly stated.

Yes, as you said that, we tried to say that few studies have conducted activity participations combined with other lifestyle factors such as physical activity and nutrition. We realized that this sentence is not clear, so we changed it as below.

“Although there is evidence that engagement in a variety of activities affects health outcomes, few studies have examined, including activity participation along with other lifestyle factors such as physical activity and nutrition.”

• P.17, lines 202-203: “we were able to assess the life-balance” – you did not assess this, you assessed the opinions of experts and it would be clearer for the reader if you stated that clearly here.

As you pointed out, that sentence was not appropriate because it is not based on the results, thus we decided to delete it so as to avoid misunderstanding of the reader.

4. ABSTRACT

• P.2, line 29: “… questions reconstructed regarding the evaluation items …” – this meaning of this sentence is not clear to me. I am not able to suggest changes, but it should be rewritten to convey its meaning more clearly.

We agreed that the sentence make the readers confused. Thus we deleted some unnecessary words and make it more clear sentence as below.

‘The first survey gathered opinions using a mix of open- and closed-ended questions regarding items of the older adults' multifaceted lifestyle profile.’

Attachment

Submitted filename: Response to Reviewer2.pdf

Click here for additional data file. (205.3KB, pdf)

Decision Letter 1

Gianluigi Forloni

8 May 2020

Development of an elderly lifestyle profile: A Delphi survey of multidisciplinary health-care experts

PONE-D-20-05504R1

Dear Dr. Park,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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Reviewer #2: Yes

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Reviewer #1: No other comments or suggestions. The article has greatly improved. The authors revised and modified the text and references correcting any errors and completing the incomplete ones. In the "conclusions" they reported the importance of the ethnic-geographical context for research like this, following the suggestion. The results are interesting and could be the basis for other research on the same topic.

Reviewer #2: Thank you for addressing the comments from the review process and clarifying queries and concerns raised. I feel that your manuscript is greatly improved. I have two comments arising from your revision which need to be corrected to improve the language used:

1. p6, line133: while the revised wording is better I feel it would be much clearer to simply state: a neutral middle point was not included to force participants to provide their opinion (or response). The wording obvious opinions is confusing.

2. p.19, line 221: the revised wording has improved the sentence, however I suggest removing the word 'including' to make it clearer - few studies have examined activity participation along with other lifestyle factors such as physical activity and nutrition.

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Acceptance letter

Gianluigi Forloni

15 May 2020

PONE-D-20-05504R1

Development of an elderly lifestyle profile: A Delphi survey of multidisciplinary health-care experts

Dear Dr. Park:

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