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. 2023 Jan 3;18(1):e0279199. doi: 10.1371/journal.pone.0279199

Importance of feeding status evaluation in older patients undergoing hemodialysis

Satoko Notomi 1, Mineaki Kitamura 1,2,*, Noriko Horita 3, Kosei Yamaguchi 1,2, Takashi Harada 1, Tomoya Nishino 2, Satoshi Funakoshi 1, Yasuyo Abe 3
Editor: Mabel Aoun4
PMCID: PMC9810173  PMID: 36595498

Abstract

Older hospitalized patients undergoing hemodialysis are increasingly experiencing malnutrition caused by dysphagia. However, only a few studies have focused on this problem. We used the Kuchikara Taberu Balance Chart (KTBC) to evaluate the patients’ feeding status and examined its association with their nutritional status and prognosis. This study included elderly patients undergoing hemodialysis who were hospitalized at Nagasaki Renal Center for > 3 days between June 2021 and February 2022. In total, 82 inpatients were included [mean age, 73.4 ± 10.0 years; men, 57.3%; median dialysis vintage, 79.0 months (interquartile range, 37.3–164.8)]. We classified patients with lower than the median KTBC score (57 points) as being at risk for dysphagia; 37 patients (45.1%) were at risk for dysphagia. Spearman’s rank correlation coefficient (ρ) elucidated that the KTBC total score was significantly associated with each nutritional indicator [serum albumin level (ρ = 0.505, p < 0.001); geriatric nutritional risk index (ρ = 0.600, p < 0.001); and nutritional risk index (ρ = -0.566, p < 0.001)]. The KTBC score was also closely associated with the body mass index (ρ = 0.228, p = 0.04). Patients with a lower KTBC score showed poor prognosis (log-rank test: p = 0.001), and age- and sex-adjusted Cox proportional analysis showed that the KTBC score was associated with life prognosis (hazard ratio, 0.90; 95% confidential interval, 0.86–0.94; p < 0.001). Therefore, we concluded that the patients at risk of dysphagia, identified using the KTBC score, were malnourished and had a poor prognosis. Hence, the evaluation of dysphagia using the KTBC is encouraged to prevent malnutrition in vulnerable older patients undergoing hemodialysis.

Introduction

Nutritional problems have been highlighted in older patients undergoing hemodialysis in Japan [1]. Among diseases and health complications in older adults, stroke and dementia can evoke high rates of dysphagia [2], which is known to be associated with malnutrition [3]. These complications and mental problems (i.e., dementia) of older patients undergoing hemodialysis [4–7] can also have a negative impact on activities of daily living, feeding status, and nutritional status, thus, resulting in poor prognosis [8, 9]. However, the dysphagia status has not been commonly evaluated at dialysis facilities compared to nursing homes. It would be important to conduct feeding status evaluation to prevent malnutrition at dialysis facilities.

The Kuchikara Taberu Balance Chart (KTBC) is a questionnaire-based evaluation tool for feeding status, including dysphagia, developed in Japan in 2015 [10]. The KTBC has been previously shown to be reliable and valid for the evaluation of swallowing [11]. It consists of 13 factors related to physical, nutritional, and medical conditions [12], and parameters that can be evaluated objectively based on medical records, such as fever, times of suction, use of artificial teeth, need for assistance during meals, and food modification, were used for evaluation [10]. Thus, the KTBC is non-invasive [11] and easy to use for medical staffs. However, there are no previous studies evaluating the feeding status of older patients undergoing hemodialysis with KTBC.

We hypothesized that dysphagia is associated with poor prognosis via malnutrition in older patients undergoing hemodialysis. This study aimed i) to examine the feeding status, including dysphagia, using the KTBC, and elucidate the factors related to dysphagia; and ii) to reveal the association between the feeding and nutritional status and life prognosis.

Materials and methods

Study design

This is a retrospective study from the time of KTBC evaluation to the end of February 2022. We examined the association between feeding status evaluated by KTBC, nutritional status, and life prognosis. This study was approved by the Institutional Review Board (22001) of Nagasaki Renal Center (Nagasaki, Japan) and was conducted following the 1964 Declaration of Helsinki and its subsequent amendments. Although the patients in this study were informed of their participation, the ethics committee waived the requirement for consent based on the retrospective nature of the analysis and the anonymization of the patients’ data.

Participants

This study included patients undergoing hemodialysis who were admitted to the Nagasaki Renal Center (Nagasaki, Japan) during the observation period. Patients with dialysis duration ≥ 3 months were included. Patients who were hospitalized for chemotherapy, those who left our facility before the evaluation of dysphagia, those hospitalized for < 3 days, those on enteral nutrition, and those who were transferred to another hospital within 1 month were excluded. The KTBC was evaluated at least 3 days after admission to hospital. For patients with multiple hospitalizations during the observation period, the evaluation conducted at the first admission was used in this study.

Data collection

Patient characteristics, including age, sex, duration of dialysis, and health complications, such as diabetes mellitus, ischemic heart disease, and arteriosclerosis obliterans, were obtained from description of pre-existing diseases in medical records. Dementia was determined by assessing Mini-Mental State Examination [13] or according to a previous diagnosis. Nutritional indicators, namely the serum albumin level, GNRI, and NRI were obtained from routine blood examinations conducted every month. To examine the association with the KTBC score and nutritional indicators briefly, we focused on the nutritional indicators of the closest month at the time of KTBC evaluation. Blood tests were routinely conducted at the beginning of dialysis treatment (not fasting). Serum albumin was analyzed using the bromocresol green method. According to the protein energy wasting (PEW) criteria, reported by the International Society of Renal Nutrition and Metabolism, serum albumin levels < 3.8 g/dL indicate the risk of malnutrition [14]. The GNRI was calculated based on patient serum albumin levels and body weight using a modified formula proposed by Yamada, et al. (2008): GNRI = [14.89 × albumin (g/dL)] + [41.7 × (body weight/ideal body weight); for Body Mass Index (BMI) > 22 kg/m2, body weight/ideal body weight = 1] [15]. A GNRI < 91.2 was defined as risk of malnutrition [15]. The NRI was evaluated based on age, serum albumin level, BMI, total cholesterol, and serum creatinine levels, as described in a previous study [16]. An NRI ≥ 11 was defined as high risk of malnutrition [16]. The KTBC was used to evaluate the dysphagia of inpatients, with each factor rated from 1 (worst) to 5 (best) points [11]. The evaluation criteria for each factor were defined by the developer of the KTBC [10]. Dysphagia was evaluated by a trained registered dietitian who was blinded to blood examination data. Patients were divided into two groups based on their median KTBC total score. In addition to the KTBC total score, we focused on six major factors in the KTBC score (“overall condition,” “cognitive function while eating,” “severity of pharyngeal dysphagia,” “position and endurance while eating,” “food modification,” and “nutrition”).

Statistical analysis

Categorical values are shown as numbers (in %), and continuous variables are shown as mean ± standard deviation or median values with interquartile ranges. The Wilcoxon Sum Rank test was used to compare the two groups. Spearman’s rank correlation coefficient (ρ) was used to examine the association between the KTBC score and nutritional parameters such as serum albumin level, GNRI, NRI, and monthly BMI decrease. A logistic regression analysis was conducted to elucidate the association between a lower KTBC total score (less than median) and patient background factors, such as age, sex, dialysis vintage, and health complications. A multivariable logistic regression analysis was conducted using the parameters with p < 0.05 in the univariable logistic regression analysis. Kaplan–Meier curves were used to show the survival rate for the two groups, and the log-rank test was used to compare the groups. Cox proportional analysis was used to evaluate the risk of mortality, including the KTBC total score, age, sex, dialysis vintage, and health complications. Age- and sex-adjusted Cox proportional hazards analyses were also performed. Statistical significance was set at p < 0.05. All statistical analyses were performed using JMP 15 software (SAS Institute Inc., Cary, NC, USA).

Results

Patient background

During the observation period, 150 patients undergoing hemodialysis were admitted to Nagasaki Renal Center. After excluding 68 patients, 82 inpatients (age 73.4 ± 10.0 years; male, 57.3%) were analyzed. The patient information flow chart is presented in Fig 1. Major reasons for hospitalization were difficulty in moving and staying at home (n = 36), continued pneumonia (n = 6), fever (n = 5), and enteritis (n = 5). The median KTBC total score was 57 (interquartile range: 50–61) points; 37 patients had a lower score than the median KTBC total score. The demographic features of the patients divided by a KTBC score of 57 points are shown in Table 1. There were significant differences in stroke history, dementia, BMI, serum albumin level, GNRI, and NRI between the two groups.

Fig 1. Patients’ flow chart.

Fig 1

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Table 1. Summary of patient background.

Total (n = 82) KTBC total score (< 57) (n = 37) KTBC total score (≥ 57) (n = 45) p
Age (years) 73.4 ± 10.0 74.5 ± 12.3 72.5 ± 7.8 0.44
Sex, n (%)
 Male 47 (57.3%) 22 (59.5%) 25 (55.6%) 0.72
 Female 35 (42.7%) 15 (40.5%) 20 (44.4%)
Dialysis vintage (months) 79.0 (37.3–164.8) 57.0 (38.0–120.0) 95.0 (34.5–193.5) 0.13
Diabetes mellitus history 38 (46.3%) 20 (54.1%) 18 (40.0%) 0.20
Ischemic heart disease history 34 (41.5%) 15 (40.5%) 19 (42.2%) 0.88
Stroke history 18 (22.0%) 12 (32.4%) 6 (13.3%) 0.04
Arteriosclerosis obliterans 17 (20.7%) 7 (18.9%) 10 (22.2%) 0.71
Dementia 22 (26.8%) 15 (40.5%) 7 (15.6%) 0.01
Serum albumin level (g/dL) 3.1 (2.7–3.3) 2.8 (2.6–3.2) 3.2 (3.0–3.6) < 0.001
Geriatric nutritional risk index 82.4 ± 9.35 77.45 ± 9.73 86.50 ± 6.74 < 0.001
Nutritional risk index 9.0 (5.8–11.0) 11.0 (9.0–12.0) 8.0 (4.5–9.0) < 0.001
Body mass index 20.2 (17.8–21.8) 18.3 (16.5–20.8) 21.3 (19.1–22.0) 0.001
Kuchikara Taberu Balance Chart total score 57.0 (50.0–61.0) 49.0 (41.5–53.0) 60.0 (58.0–62.0) < 0.001
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Wilcoxon sum test, paired-t-test and chi-square test were used for analysis.

Feeding status evaluated using the KTBC and its association with nutritional status or life prognosis

The histogram of the KTBC total score is shown in Fig 2. Approximately one-third of our participants had a total score > 60 points.

Fig 2. Histogram of the KTBC total score.

Fig 2

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The KTBC total score was significantly correlated with serum albumin level (ρ = 0.505, p < 0.001), GNRI (ρ = 0.600, p < 0.001), and NRI (ρ = -0.566, p < 0.001; Fig 3a–3c). Of the 82 patients, 76 (92.7%) were suspected of having malnutrition according to their serum albumin levels (Fig 3a), 67 (81.7%) were defined as being at risk of malnutrition per the GNRI (Fig 3b), and 32 (39.0%) were defined as being at risk of malnutrition per the NRI (Fig 3c). Additionally, the KTBC total score was significantly associated with monthly decrease in BMI (ρ = 0.228, p = 0.04; Fig 4).

Fig 3. Association between the KTBC total score and nutritional status; a. serum albumin level, b. GNRI, and c. NRI.

Fig 3

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Fig 4. Association between the KTBC total score and percentage BMI decrease.

Fig 4

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Univariable logistic regression analysis for a lower KTBC score was conducted based on patient characteristics. BMI, stroke history, and dementia were significantly associated with KTBC (p < 0.05). Next, we conducted a multivariable logistic regression analysis including these parameters; lower KTBC scores were associated with BMI only (odds ratio, 0.79; 95% confident interval 0.66–0.93, p = 0.004; Table 2).

Table 2. Logistic regression models for lower Kuchikara Taberu Balance Chart (< 57 points).

Univariable Multivariable
OR 95%CI p OR 95%CI p
Lower Upper Lower Upper
Age per 1 year old 1.02 0.98 1.07 0.37
Male vs. Female 1.17 0.49 2.86 0.72
Dialysis vintage per 1 month 0.96 0.92 1.01 0.10
Body Mass Index per 1 kg/m2 0.77 0.64 0.90 0.001 0.79 0.66 0.93 0.004
Diabetes mellitus history 1.76 0.74 4.31 0.20
Ischemic heart disease history 0.93 0.38 2.26 0.88
Stroke history 3.12 1.07 9.97 0.04 2.69 0.83 9.41 0.10
Arteriosclerosis obliterans 0.82 0.27 2.39 0.71
Dementia 3.70 1.35 11.02 0.011 2.86 0.95 9.17 0.06
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OR, odds ratio; CI, confidence interval.

The median observation period was 118 days (interquartile range, 71–217 days). Of 82 patients, 25 died during the observation period. In our participants, cardiovascular disease was the most common cause of death (32.0%), followed by infectious complication (12.0%) and ileus (8.0%). Other major causes of death include cancer, multiple organ failure, and aspiration pneumonia, each accounting for 4.0% of cases of death. A log-rank analysis showed that patients with lower KTBC scores had poorer prognosis than those with higher scores (p = 0.001; Fig 5). Univariable Cox proportional analysis indicated that age, BMI, dementia, and KTBC score were associated with patient prognosis. Further, age- and sex-adjusted Cox proportional analysis showed that the BMI (hazard ratio, 0.86; 95% confidence interval, 0.75–0.99; p = 0.04) and the KTBC total score (hazard ratio, 0.90; 95% confidence interval, 0.86–0.94; p < 0.001) were associated with life prognosis (Table 3).

Fig 5. Kaplan–Meier analysis of participants.

Fig 5

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Table 3. Cox regression analysis for all-cause mortality.

Univariable Age sex ajusted
HR 95%CI p HR 95%CI p
Lower Upper Lower Upper
Age per 1 year old 1.05 1.01 1.10 0.01 1.05 1.01 1.10 0.01
Male v.s. Female 1.41 0.62 3.20 0.41 1.42 0.63 3.22 0.40
Dialysis vintage per 1 month 1.01 0.97 1.04 0.69 1.04 1.00 1.09 0.07
Body Mass Index per 1 kg/m2 0.85 0.75 0.97 0.01 0.86 0.75 0.99 0.04
Diabetes mellitus history 0.78 0.35 1.72 0.54 0.95 0.41 2.16 0.90
Ischemic heart disease history 0.88 0.40 1.97 0.73 0.91 0.41 2.04 0.82
Stroke history 0.69 0.26 1.85 0.46 0.83 0.30 2.26 0.71
Arteriosclerosis obliterans 0.88 0.35 2.21 0.78 1.06 0.39 2.89 0.91
Dementia 2.46 1.12 5.40 0.03 2.03 0.83 4.97 0.12
Kuchikara Taberu Balance Chart total score 0.90 0.86 0.93 < 0.001 0.90 0.86 0.94 < 0.001
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HR, hazard ratio; CI, confidence interval.

Association between major factors of the KTBC and dementia or nutritional indicators

Dementia was significantly associated with feeding problems, such as cognition (p = 0.01), swallowing (p < 0.001), and posture maintenance during meals (p = 0.01; S1 Table). Among the major factors of the KTBC, food modification was strongly associated with all nutritional indicators (p < 0.001 for serum albumin level, GNRI, and NRI). Serum albumin level was more highly associated with over-all condition (p = 0.001) than with nutrition (p = 0.07; S2 Table).

Discussion

To our knowledge, this is the first study that evaluated the feeding status, including dysphagia, of older patients undergoing hemodialysis using the KTBC. The KTBC has several advantages as it is non-invasive, easy to evaluate, and has an accuracy equivalent to videoendoscopic examination of swallowing function. High sensitivity of KTBC with respiratory conditions and postural endurance have been reported in a previous study [17]. As our older patients had many difficulties related to maintenance of posture due to several health complications, the KTBC was considered a suitable tool to verify the effect on posture maintenance on feeding status. Although we focused on elderly patients in this study, 11 patients (13%) were under 60 years old because all patients hospitalized during the observation period were included. As the mean age of our participants was over 70 years old, we assume that the result of this study reflected the actual feeding status of elderly patients undergoing hemodialysis.

Approximately one-third of our participants had a score > 60 points (90% of the KTBC total scores), indicating that the feeding status of our participants was generally good. However, this study revealed that patients with lower KTBC scores, who were at risk of dysphagia, were undernourished, and had a poor prognosis; these findings were consistent with the findings of previous studies [18, 19].

Our study elucidated the significant association between the KTBC scores and BMI. This association can be explained by two possible mechanisms. One aspect is low BMI as a cause of poor feeding status; BMI is related with swallowing function that is associated with muscle mass. Previous studies have suggested that patients undergoing hemodialysis tend to lose their muscle mass, which leads to weakened swallowing function [20–22]. A decrease in muscle mass results in weakness [23] and loss of mobility [24]; these changes can negatively correlate with the effective flow of swallowed materials [2]. Therefore, a lower BMI can lead to poor feeding status. Another aspect is low BMI as a result of poor feeding status; patients with feeding difficulties consume limited food and liquid [2] leading to energy and protein shortages that further lead to malnutrition and a lower BMI. Considering these two aspects, patients with a lower BMI and risk of dysphagia consume less food, resulting in further weight loss. Thus, dysphagia is a gateway to a vicious circle of malnutrition leading to poor prognosis. Our participants were older; approximately one third of the patients were aged > 80 years. The elderly population is easy to be in “frail” situation, which is known as a state of vulnerability to poor homeostasis resolution after a stressor event [25]. Hospitalization may be a stressor to our older participants, and the patients were more likely to be in a vicious cycle of malnutrition related to dysphagia.

For patients undergoing hemodialysis, a lower BMI is known to be a greater mortality risk factor [26], and unlike in the general population, a higher BMI is associated with survival advantage; this is known as “reverse epidemiology” [27]. Although the cause of this reverse epidemiology has not been fully elucidated, one of the reasons could be that patients with a lower BMI are more susceptible to inflammation leading to a type of malnutrition, called PEW [26]. PEW evokes disordered catabolism, thus, leading to muscle loss [28]. Malnutrition and muscle loss affect cardiovascular disease negatively, which is a major cause of mortality in patients undergoing hemodialysis [29]. Additionally, as the immune system is susceptible to malnutrition, PEW can affect infectious complications negatively, which is also a major cause of mortality [30]. Our older “frail” hospitalized patients with low BMI were easy to be in PEW situation, and muscle loss leading to dysphagia was likely to occur. Moreover, dysphagia can cause further weight loss. In our participants, cardiovascular disease was the most common cause of death, followed by infectious diseases. Aspiration pneumonia was also one of the causes of death. This may suggest that a low BMI related to dysphasia was associated with death and life prognosis. In our participants, the median BMI was 20.2 kg/m2; in few individuals with obesity, however, a higher BMI with better feeding status was associated with higher survival rates. Although previous studies on reverse epidemiology have not discussed the nutritional status of the elderly, dysphagia in older patients undergoing hemodialysis might be considered one of the appearances of reverse epidemiology. Therefore, the evaluation of dysphagia is crucial to maintain good life prognosis.

Patients with dementia tended to have a poor feeding status related to poor cognition, swallowing, and posture maintenance conditions. Loss of appetite, mastication disorder, and dysphagia caused by dementia delay oral transit time [31] and evoke difficulties in self-feeding [2]. Our participants were old, 26.8% of them had dementia, and many of them were classified as having poor feeding status. According to the description of medical records, most of the patients with dementia need assistance to eat. As stated in literature, difficulties in oral intake and self-feeding may occurred in patients with dementia, and these could be difficulty in eating independently. With the aging process in patients undergoing hemodialysis, effective measures against dysphagia caused by dementia should be implemented at dialysis facilities.

In addition to BMI, nutritional indicators, such as serum albumin levels, GNRI, and NR, were significantly correlated with the KTBC total score. Examining the association between KTBC major factors and nutritional indicators, the characteristics of each indicator are explained as follows. A previous study suggested that the serum albumin level reflected malnutrition and protein loss caused by catabolism and inflammation [32]. In this study, the serum albumin levels were more strongly associated with over-all condition than with nutrition. Hence, it could be possible to use the serum albumin level as not only a nutritional indicator but also an indicator of pathophysiological status. In this study, the GNRI and the NRI reflected the feeding status almost equally.

This study revealed that patients at risk of dysphagia were undernourished and had a poor prognosis. Based on the evaluation of KTBC, the following measures may be important. First, the management of posture during meals for patients with dementia. Our patients with dementia had difficulty maintaining the posture, leading to a poor feeding status. Previous studies have suggested that chin tuck or head tilt posture maintenance changes the speed and flow direction of food and improves the safety of swallowing [33, 34]. This could be one of the approaches to prevent aspiration. Second, the improvement of paste meals for patients at risk of dysphagia. This study revealed that “food modification” was strongly associated with malnutrition. In KTBC, patients who eat paste meals are rated one (worst); that means patients who eat paste meals tend to have malnutrition. Paste meals contain a relatively large amount of water to enable stirring and swallowing; consequently, substantial amounts of ingredients decreased, leading to reduced energy and protein intake. A previous study suggested that adding oil to food could be an alternative nutritional method for patients with dysphagia [35], as lipids are high in calories, and suitable for adjusting the rheological properties of foods [35]. Further studies are needed to verify the effect of adding oil to food. Third, the examination of appropriate nutritional supplements for patients at risk of dysphagia. This study revealed that maintaining optimal BMI is an advantage for survival, however our participants without enteral nutrition showed a -0.48% (-1.44–0%) decrease in BMI during the observation period. Although we excluded patients on enteral nutrition from the analysis, they tended to have a lower rate of BMI decrease despite the lower KTBC total score [BMI decrease, -0.09% (-0.79–0.41%); KTBC total score, 27 (22–40) points]. This means that enteral nutrition is an alternative method that can supply adequate energy and protein for patients at risk of dysphagia. Fourth, the improvement of the swallowing function. Several studies have reported that swallowing function was improved by interventions, such as oral care, for issues revealed by KTBC evaluation [12, 36–38]. Recent evidence suggests that swallowing rehabilitation and early preventive efforts are essential for preventing dysphagia. Intervention studies have examined improvements in life prognosis by nutritional intervention and swallowing rehabilitation [39, 40]. As this is a retrospective study based on clinical practice, it was difficult to standardize the timing of KTBC evaluation. It would be desirable to establish a protocol for early evaluation and intervention during hospitalization to prevent malnutrition.

However, this study has several limitations. As our participants were limited to older patients undergoing hemodialysis, the results may have been influenced by the participants’ characteristics. Additionally, the association between the feeding and nutritional status was examined in a cross-sectional manner. To apply the results of this study to the general elderly population, evaluation of dysphagia using the KTBC in a larger sample at diverse facilities is needed. We used the BMI as a nutritional indicator related to dysphagia; however, we did not consider body fluid removal during the dialysis session. Therefore, the results did not reflect the body composition or edema status of patients. Additionally, as dysphagia is related to muscle capability, indicators reflecting muscle function should also have been considered.

Conclusions

Patients at risk of dysphagia, as measured by the KTBC, have a poor prognosis. As the KTBC is associated with nutritional indicators, malnutrition has a negative impact on patient prognosis. As older patients undergoing hemodialysis are more vulnerable to dysphagia, the evaluation of dysphagia using the KTBC could be one of clinical assessment tools to prevent malnutrition.

Supporting information

S1 Data. Patients’ data are supplied in a supporting information file.

(XLSX)

Click here for additional data file. (38.3KB, xlsx)
S1 Table. Association between major items of the Kuchikara Taberu Balance Chart and dementia.

Wilcoxon sum rank test was used.

(DOCX)

Click here for additional data file. (17.3KB, docx)
S2 Table. Association between major items of the Kuchikara Taberu Balance Chart and nutritional indicators.

Spearman’s rank correlation coefficient was used.

(DOCX)

Click here for additional data file. (19.3KB, docx)

Acknowledgments

We convey our special thanks to healthcare workers for supporting this study.

Data Availability

All relevant data are within the paper and its Supporting information files.

Funding Statement

The authors received no specific funding for this work.

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Decision Letter 0

Leonardo Costa Pereira

6 Sep 2022

PONE-D-22-12985Impact of feeding status evaluated by the Kuchikara Taberu Balance Chart on nutrition and life prognosis in older patients undergoing hemodialysisPLOS ONE

Dear Dr. Kitamura,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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ACADEMIC EDITOR:After observing the reviewers' comments, and carrying out a new reading, I believe that the manuscript needs several urgent changes. In this way, we invite the authors to review the title, reinforce the idea of justification. Still, that the need to review the results and re-write several parts of the discussion in a more assertive way. In this way, we hope that you will take note of the reviewers' comments and try to respond to them promptly.

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Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: 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: This manuscript describes the evaluation of patients’ feeding status, undergoing hemodialysis, from Kuchikara Taberu Balance Chart (KTBC) and its association with their nutritional status and prognosis. The authors verified interesting associations and results of utilization of KTBC.

In general, the manuscript is interesting and brings important information’s about the theme studied.

I have some suggestions about the manuscript.

Title

The title is long, I recommend shortening it.

Keywords

The keywords must be modified, the authors repeat some words from the title.

Introduction

In general, the introduction is good, but, according to me, could be improved, especially the first two paragraphs.

Material and Methods

It is important to note that in this section, all information must be very detailed.

Then this section should be revised and improved.

For example:

1) “Data Collection”: some important information is missing, such as: a) All the health complications assessed should be listed; b) how the “dementia” was assessed? From medical records? This information is unclear.

2) How long time/months have the nutritional indicators (serum albumin level, GNRI, and NRI were obtained from routine blood examinations conducted every month) been obtained? This information is in “Results” section, but it is part of the MM and should be further explained in this section.

Discussion

In general, this section should be improved.

The authors explain their results with the literature, but, in my opinion, the discussions should be extended with examples and comparisons in the literature, and the age condition should be further discussed.

The authors affirm that a limitation of this study is “Evaluation of dysphagia using the KTBC in a larger sample at multiple centers is needed to examine generalizability of the results. The timing of the evaluation varied depending on the case. It would have been ideal to perform a KTBC assessment of all patients within a certain period post admission in our hospital.” About this statement, I have some suggestions/questions:

- The authors could discuss this important point of view in the “discussion” section;

- Considering this limitation, is it prudent to conclude that “the evaluation of dysphagia using the KTBC is highly recommended to prevent malnutrition.”? I don’t think so.

Reviewer #2: I would like to congratulate the authors for their interesting work. This is a retrospective study and therefore limited to its design. Despite this, it is relevant and has been well conducted. This study will contribute to clinical practice and the attention of health professionals regarding nutritional status and dysphagia. However, I have several comments and believe that some issues could be clarified and some sections could be better organized.

TITLE

I think it would be interesting to clarify what the use of the word nutrition wants to convey. Nutritional status? Therefore, I suggest adjusting the title.

ABSTRACT

Adequate and concise. I suggest just mentioning in line 6 that they are elderly patients, and the percentage value in parentheses is equivalent to n=37 (line 10).

INTRODUCTION

I suggest deleting the part of the third paragraph about the EAT-10 related information. It can be included in the discussion section if the authors wish. I think it would be the most appropriate session, precisely because it was not used in the study and contributed to making the introduction unnecessarily long.

It is not usual to mention figures in the introduction section. The manuscript already has three tables and six figures. There is no need to exemplify the KTBC tool. If the authors wish to keep Figure 1, I suggest using the methods when citing the tool or presenting the study's radar chart in the results.

The fourth paragraph, it's confusing and repetitive. I recommend making the objectives clear to the reader, including that they are elderly patients.

MATERIALS AND METHODS

In the Study design section, some information presented is duplicated, such as the data collection period until February 2022 (page 5, line 18; page 6, line 6; page 9, line 6), as well as for the nutritional indicators on pages 6 and 7. These can be presented in the Data collection section. The Study design section is large and with varied information, not only about the study design. I recommend including a Participants section to present the sample and eligibility criteria.

I did not understand the inclusion criterion of being over 20 years old. Is this not a sample of elderly patients?

Authors should value the methods section and present missing information. In Data Collection, detail the sociodemographic and clinical characteristics collected. Nutritional indicators may or may not be part of a separate section, but blood tests conditions (e.g., fasting or not?) and analysis methods (e.g., albumin, colorimetric bromocresol green method?) must be described. Was there any care in measuring weight due to changes in blood volume and edema in this population?

Figure 2: There is no need to repeat the collection period in the third text box, as it was already presented in the first. If the KTBC was performed after three days of hospitalization, shouldn't the sample with hospitalization less than three days (n=25) from the second exclusion text box be in the first exclusion step? Before having your data collected?

Is it not possible to adopt a plausible cut-off point for the value of albumin in this population, as was done for the GNRI and the NRI?

In Statistical analysis, line 9 has a missing parenthesis.

RESULTS

In the Patient background section, Figure 2 is presented the methods and results. Some researchers and reviewers consider it as part of the method and others as a first result. I recommend that the authors choose which of the two sessions will mention in figure 2. In the results, there is no need to describe the figure step. It could be something more general.

The first mention in the text about Table 1 does not present the main information in the text (page 9, line 14). This content is out of place on page 11 (between lines 8 and 11). I recommend making a single mention of Table 1 with the main findings presented in a general way at the beginning of the results session.

Present in the text comments on Figure 3.

ALL FIGURES AND TABLES: Whenever possible, use a full title for clarity for the reader.

DISCUSSION

I recommend avoiding mentioning the tables and figures in this section.

On page 17 (line 11), include the BMI unit and avoid using pejorative or stigmatizing language (e.g., “few were obese” by a few individuals with obesity).

Regarding reverse epidemiology, I think it is necessary to consider the other side of studies related to the topic. Many are inconsistent, some use BMI as a marker of adiposity, which does not measure central adiposity. At the same time, we know that the major cause of mortality in this population is attributed to cardiovascular disease.

Regarding limitations, it is necessary to mention the limitation of the use of BMI and possibly the lack of an adequate parameter for more effective conclusions through the assessment of body composition and muscle function, whether strength or functional capacity of elderly individuals and its relationship with dysphagia.

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Reviewer #1: No

Reviewer #2: No

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PLoS One. 2023 Jan 3;18(1):e0279199. doi: 10.1371/journal.pone.0279199.r002

Author response to Decision Letter 0

19 Sep 2022

AUTHORS’ RESPONSES TO REVIEWERS’ COMMENTS

Reviewer 1

We would like to thank Reviewer 1 for the time and effort taken to review our manuscript and for providing valuable comments and suggestions, which have considerably helped us improve our manuscript. We have made every effort to address the issues raised and to respond to all comments. The revisions are indicated in red font in the revised manuscript. Please, fine next a detailed, point-by-point response to the reviewer’s comments. We hope that our revisions will meet the reviewer’s expectations.

Title

The title is long, I recommend shortening it.

Response: Please note that we have shortened the title to convey our idea more clearly.

Keywords

The keywords must be modified, the authors repeat some words from the title.

Response: Following the reviewer’s suggestion, we have changed the title and reviewed the key words. We have tried to avoid using the same terms in the title.

Introduction

In general, the introduction is good, but, according to me, could be improved, especially the first two paragraphs.

Response: We agree with the reviewer that the Introduction section of the previous version of our manuscript was redundant and too long. Therefore, we have revised it accordingly. In the first paragraph, we have summarized the complications of patients undergoing hemodialysis and excluded duplicate text. In the second paragraph, we have summarized the contents combined with the previous third paragraph and presented an overview of the KTBC. Moreover, we have moved the details of the KTBC to the Discussion section.

Material and Methods

It is important to note that in this section, all information must be very detailed.

Then this section should be revised and improved.

For example:

1) “Data Collection”: some important information is missing, such as: a) All the health complications assessed should be listed; b) how the “dementia” was assessed? From medical records? This information is unclear.

Response: Please note that we have collected information concerning diabetes mellitus history, ischemic heart history, stroke history, and arteriosclerosis from the description of pre-existing disease in medical records.

Dementia was determined by assessing the Mini-Mental State Examination, which is known as a validated assessment tool, or according to a previous diagnosis. We have provided this information in the Materials and Methods section as follows:

“Dementia was determined by assessing Mini-Mental State Examination [13] or according to a previous diagnosis.” (Page 6, lines 4–5)

2) How long time/months have the nutritional indicators (serum albumin level, GNRI, and NRI were obtained from routine blood examinations conducted every month) been obtained? This information is in “Results” section, but it is part of the MM and should be further explained in this section.

Response: The serum albumin levels were assessed monthly using routine blood tests. The GNRI and NRI were calculated using the results of monthly blood tests. To examine the association with the KTBC score and the nutritional status briefly, we focused on the nutritional indicators of the closest month at the time of KTBC evaluation. We have provided this information in the Materials and Methods section as follows:

“To examine the association with the KTBC score and nutritional indicators briefly, we focused on the nutritional indicators of the closest month at the time of KTBC evaluation. Blood tests were routinely conducted at the beginning of dialysis treatment (not fasting). Serum albumin was analyzed using the bromocresol green method. According to the protein energy wasting (PEW) criteria, reported by the International Society of Renal Nutrition and Metabolism, serum albumin levels < 3.8 g/dL indicate the risk of malnutrition [14].” (Page 6, lines 7–13)

Discussion

In general, this section should be improved.

The authors explain their results with the literature, but, in my opinion, the discussions should be extended with examples and comparisons in the literature, and the age condition should be further discussed.

Response: We agree with the reviewer that we should have extended the Discussion section. Following the reviewer’s suggestion, we compared the findings from the literature with those of our elderly participants. For example, we explained the mechanism of association with low BMI and dysphagia, reverse epidemiology, and the association with dementia and dysphagia using the literature. Then, we compared the results of this study as follows:

“Our participants were older; approximately one third of the patients were aged > 80 years. The elderly population is easy to be in “frail” situation. Which is known as a state of vulnerability to poor homeostasis resolution after a stressor event [25]. Hospitalization may be a stressor to our older participants, and the patients were more likely to be in a vicious cycle of malnutrition related to dysphagia.” (Page 15, lines 9–13)

“PEW evokes disordered catabolism, thus, leading to muscle loss [28]. Malnutrition and muscle loss affect cardiovascular disease negatively, which is a major cause of mortality in patients undergoing hemodialysis [29]. Additionally, as the immune system is susceptible to malnutrition, PEW can affect infectious complications negatively, which is also a major cause of mortality [30]. Our older “frail” hospitalized patients with low BMI were easy to be in PEW situation, and muscle loss leading to dysphagia was likely to occur. Moreover, dysphagia can cause further weight loss. In our participants, cardiovascular disease was the most common cause of death, followed by infectious diseases. Aspiration pneumonia was also one of the causes of death. This may suggest that a low BMI related to dysphasia was associated with death and life prognosis.” (Page 16, lines 1–11)

“Although previous studies on reverse epidemiology have not discussed the nutritional status of the elderly, dysphagia in older patients undergoing hemodialysis might be considered one of the appearances of reverse epidemiology.” (Page 16, lines 14–16)

“According to the description of medical records, most of the patients with dementia need assistance to eat. As stated in literature, difficulties in oral intake and self-feeding reported may have occurred in patients with dementia and these could lead to difficulty in eating independently.” (Page 17, lines 5–8)

We considered the “frail” characteristics of our elderly hospitalized patients as follows:

“Our participants were older; approximately one third of the patients were aged > 80 years. The elderly population is easy to be in “frail” situation, which is known as a state of vulnerability to poor homeostasis resolution after a stressor event [25]. Hospitalization may be a stressor to our older participants, and the patients were more likely to be in a vicious cycle of malnutrition related to dysphagia.” (Page 15, lines 9–13)

“Our older “frail” hospitalized patients with low BMI were easy to be in PEW situation, and muscle loss leading to dysphagia was likely to occur. Moreover, dysphagia can cause further weight loss. In our participants, cardiovascular disease was the most common cause of death, followed by infectious diseases. Aspiration pneumonia was also one of the causes of death. This may suggest that a low BMI related to dysphagia was associated with death and life prognosis.” (Page 16, lines 6–11)

The authors affirm that a limitation of this study is “Evaluation of dysphagia using the KTBC in a larger sample at multiple centers is needed to examine generalizability of the results. The timing of the evaluation varied depending on the case. It would have been ideal to perform a KTBC assessment of all patients within a certain period post admission in our hospital.” About this statement, I have some suggestions/questions:

- The authors could discuss this important point of view in the “discussion” section;

Response: We apologize for the incoherent description. As our participants were limited to older patients undergoing hemodialysis, the results may have been influenced by the participants’ characteristics. It is difficult to apply the results of this study to the general elderly population, which was a limitation. We have discussed this issue in the revised manuscript as follows:

“As our participants were limited to older patients undergoing hemodialysis, the results may have been influenced by the participants’ characteristics. Additionally, the association between the feeding and nutritional status was examined in a cross-sectional manner. To apply the results of this study to the general elderly population, evaluation of dysphagia using the KTBC in a larger sample at diverse facilities is needed.” (Page 19, line 16 – Page 20 line 6)

Additionally, as this was a retrospective study based on the clinical practice, it was difficult to standardize the timing of KTBC evaluation. This study revealed that the KTBC score was associated with a decrease in BMI over time. Therefore, it would be important to detect poor feeding status and prevent malnutrition in early hospitalization and intervene for improvement. Following the reviewer’s suggestion, we have discussed this issue in the Discussion section as follows:

“As this is a retrospective study based on clinical practice, it was difficult to standardize the timing of KTBC evaluation. It would be desirable to establish a protocol for early evaluation and intervention during hospitalization to prevent malnutrition.” (Page 19, lines 14–17)

- Considering this limitation, is it prudent to conclude that “the evaluation of dysphagia using the KTBC is highly recommended to prevent malnutrition.”? I don’t think so.

Response: We apologize for the incoherent description.

As this is a retrospective study based on clinical practice, we would like to propose KTBC as one of the clinical assessment tools for monitoring the feeding status. Please note that we have added the following sentence to the revised manuscript:

“As older patients undergoing hemodialysis are more vulnerable to dysphagia, the evaluation of dysphagia using the KTBC could be one of clinical assessment tools to prevent malnutrition.” (Page 20, lines 15–17)

Reviewer 2

We would like to thank Reviewer 2 for the time and effort taken to review our manuscript and for providing valuable comments and suggestions, which have considerably helped us improve our manuscript. We have made every effort to address the issues raised and to respond to all comments. The revisions are indicated in red font in the revised manuscripts. Please, find next a detailed, point-by point response to the reviewer’s comments. We hope that our revisions will meet the reviewer’s expectation.

TITLE

I think it would be interesting to clarify what the use of the word nutrition wants to convey. Nutritional status? Therefore, I suggest adjusting the title.

Response: As the reviewer suggested, “nutritional status” reflects the purpose of this study more than “nutrition”. Thus, we have shortened the title and adjusted it to convey our idea more clearly.

ABSTRACT

Adequate and concise. I suggest just mentioning in line 6 that they are elderly patients, and the percentage value in parentheses is equivalent to n=37 (line 10).

Response: Please note that we have mentioned that our participants were elderly patients. As the risk of dysphagia was evaluated against the median KTBC value, nearly half of the participants were classified as being at risk. We have added a percentage value in parentheses as follows:

“We classified patients with lower than the median KTBC score (57 points) as being at risk for dysphagia; 37 patients (45.1%) were at risk for dysphagia.” (Page 2, lines 9–11)

INTRODUCTION

I suggest deleting the part of the third paragraph about the EAT-10 related information. It can be included in the discussion section if the authors wish. I think it would be the most appropriate session, precisely because it was not used in the study and contributed to making the introduction unnecessarily long.

Response: We have removed the EAT-10 related information to avoid making the Introduction section unnecessarily long. Additionally, we have moved the details of the KTBC to the Discussion section.

It is not usual to mention figures in the introduction section. The manuscript already has three tables and six figures. There is no need to exemplify the KTBC tool. If the authors wish to keep Figure 1, I suggest using the methods when citing the tool or presenting the study's radar chart in the results.

Response: Please note that we have removed Figure 1 from the Introduction section.

The fourth paragraph, it's confusing and repetitive. I recommend making the objectives clear to the reader, including that they are elderly patients.

Response: Please not that we have excluded duplicate statements and numbered two aims of this study to make our objectives clear. We have also emphasized that our participants were elderly, as per the reviewer’s suggestion. The added part is as follows:

“Thus, the KTBC is non-invasive [11] and easy to use for medical staffs. However, there are no previous studies evaluating the feeding status of older patients undergoing hemodialysis with KTBC.” (Page 4, lines 4–6)

MATERIALS AND METHODS

In the Study design section, some information presented is duplicated, such as the data collection period until February 2022 (page 5, line 18; page 6, line 6; page 9, line 6), as well as for the nutritional indicators on pages 6 and 7. These can be presented in the Data collection section. The Study design section is large and with varied information, not only about the study design. I recommend including a Participants section to present the sample and eligibility criteria.

Response: We would like to apologize for the confusing description. We have reorganized the “Study design” subsection and added the “Participants” subsection to present the sample and eligibility criteria (Page 5, lines 7–15).

I did not understand the inclusion criterion of being over 20 years old. Is this not a sample of elderly patients?

Response: We would like to thank the reviewer for pointing this out. As our participants did not include patients aged ≤20 years, the inclusion criterion of age >20 years is not necessary. We have removed this part, as per the reviewer’s suggestion.

Authors should value the methods section and present missing information. In Data Collection, detail the sociodemographic and clinical characteristics collected. Nutritional indicators may or may not be part of a separate section, but blood tests conditions (e.g., fasting or not?) and analysis methods (e.g., albumin, colorimetric bromocresol green method?) must be described. Was there any care in measuring weight due to changes in blood volume and edema in this population?

Response: Our blood tests were not fasting, and the serum albumin level was analyzed by the bromocresol green method. We have added this information concerning blood tests in the Materials and Methods section as follows:

“To examine the association with the KTBC score and nutritional indicators briefly, we focused on the nutritional indicators of the closest month at the time of KTBC evaluation. Blood tests were routinely conducted at the beginning of dialysis treatment (not fasting). Serum albumin was analyzed using the bromocresol green method. According to the protein energy wasting (PEW) criteria, reported by the International Society of Renal Nutrition and Metabolism, serum albumin levels < 3.8 g/dL indicate the risk of malnutrition [14]".” (Page 6, lines 7–13)

Unfortunately, we did not use a weight scale, which can estimate fluid volume and edema of the patients. Therefore, we have discussed this issue as a limitation as follows:

“We used the BMI as a nutritional indicator related to dysphagia; however, we did not consider body fluid removal during the dialysis session. Therefore, the results did not reflect the body composition or edema status of patients. Additionally, as dysphagia is related to muscle capability, indicators reflecting muscle function should also have been considered.” (Page 20, lines 6–10)

Figure 2: There is no need to repeat the collection period in the third text box, as it was already presented in the first.

Response: Please not that we have removed the duplicate information from the third box in Figure 1 (Figure 2 before correction).

If the KTBC was performed after three days of hospitalization, shouldn't the sample with hospitalization less than three days (n=25) from the second exclusion text box be in the first exclusion step? Before having your data collected?

Response: Please note that we have corrected our mistake following the reviewer’s suggestion.

Is it not possible to adopt a plausible cut-off point for the value of albumin in this population, as was done for the GNRI and the NRI?

Response: According to protein energy wasting (PEW) criteria, reported by the International Society of Renal Nutrition and Metabolism, serum albumin levels <3.8 g/dL indicates the risk of malnutrition. We have provided this information in the Material and Methods section, and showed the cut-off point in Figure 3a, as was done for GNRI and NRI. The added part is as follows:

To examine the association with the KTBC score and nutritional indicators briefly, we focused on the nutritional indicators of the closest month at the time of KTBC evaluation. Blood tests were routinely conducted at the beginning of dialysis treatment (not fasting). Serum albumin was analyzed using the bromocresol green method. According to the protein energy wasting (PEW) criteria, reported by the International Society of Renal Nutrition and Metabolism, serum albumin levels < 3.8 g/dL indicate the risk of malnutrition [14].” (Page 6, lines 7–13)

In Statistical analysis, line 9 has a missing parenthesis.

Response: We would like to apologize for the mistake. We have corrected this in the revised manuscript.

RESULTS

In the Patient background section, Figure 2 is presented the methods and results. Some researchers and reviewers consider it as part of the method and others as a first result. I recommend that the authors choose which of the two sessions will mention in figure 2. In the results, there is no need to describe the figure step. It could be something more general.

Response: Thank you for the suggestion. We have chosen to present Figure 1 (Figure 2 before correction) in the Results session to avoid duplication.

The first mention in the text about Table 1 does not present the main information in the text (page 9, line 14). This content is out of place on page 11 (between lines 8 and 11). I recommend making a single mention of Table 1 with the main findings presented in a general way at the beginning of the results session.

Response: We would like to apologize for the confusing description. Following the reviewer’s suggestion, we have moved Table 1 at the beginning of the Results session.

Present in the text comments on Figure 3.

Response: Thank you for the suggestion. Please note that we have added comments concerning Figure 2 (Figure 3 before correction).

ALL FIGURES AND TABLES: Whenever possible, use a full title for clarity for the reader.

Response: Thank you for the suggestion. Please note that we have reviewed all figures and tables and used full titles, as per the reviewer’s suggestion.

DISCUSSION

I recommend avoiding mentioning the tables and figures in this section.

Response: Following the reviewer’s suggestion, we have removed the unnecessary parts concerning the tables and figures from the Discussion section. For example, we have excluded the detailed result of the association with KTBC and dementia. Additionally, we have also excluded the detailed description concerning Supplementary Tables from the Discussion section.

On page 17 (line 11), include the BMI unit and avoid using pejorative or stigmatizing language (e.g., “few were obese” by a few individuals with obesity).

Response: Please note that we have revised this part accordingly (Page 16, line 12).

Regarding reverse epidemiology, I think it is necessary to consider the other side of studies related to the topic. Many are inconsistent, some use BMI as a marker of adiposity, which does not measure central adiposity. At the same time, we know that the major cause of mortality in this population is attributed to cardiovascular disease.

Response: Please note that we have enhanced our discussion concerning the participant characteristics in the Discussion section as follows:

“Our participants were older; approximately one third of the patients were aged > 80 years. The elderly population is easy to be in “frail” situation, which is known as a state of vulnerability to poor homeostasis resolution after a stressor event [25]. Hospitalization may be a stressor to our older participants, and the patients were more likely to be in a vicious cycle of malnutrition related to dysphagia.” (Page 15, lines 9–13)

“PEW evokes disordered catabolism, thus, leading to muscle loss [28]. Malnutrition and muscle loss affect cardiovascular disease negatively, which is a major cause of mortality in patients undergoing hemodialysis [29]. Additionally, as the immune system is susceptible to malnutrition, PEW can affect infectious complications negatively, which is also a major cause of mortality [30]. Our older “frail” hospitalized patients with low BMI were easy to be in PEW situation, and muscle loss leading to dysphagia was likely to occur. Moreover, dysphagia can cause further weight loss. In our participants, cardiovascular disease was the most common cause of death, followed by infectious diseases. Aspiration pneumonia was also one of the causes of death. This may suggest that a low BMI related to dysphasia associated with death and life prognosis.” (Page 16, lines 1–page 16, line 11)

Indeed, cardiovascular disease is the major cause of mortality, and a previous showed that malnutrition and muscle loss can be a risk factor for cardiovascular mortality in patients undergoing hemodialysis [29]. Infectious complications are also the major cause of mortality in this population [30]. Malnourished patients tend to have a weakened immune system and are more likely to develop infectious complications.

As we mentioned in the manuscript, the mechanism of reverse epidemiology has not been elucidated fully; however, malnutrition associated with low BMI may affect major causes of mortality negatively. Especially, this negative relationship is likely to occur in “frail” hospitalized elderly patients. We have revised manuscript considering this point of view as follow:

“PEW can affect infectious complications negatively, which is also a major cause of mortality [30]. Our older “frail” hospitalized patients with low BMI were easy to be in PEW situation, and muscle loss leading to dysphagia was likely to occur. Moreover, dysphagia can cause further weight loss. In our participants, cardiovascular disease was the most common cause of death, followed by infectious diseases. Aspiration pneumonia was also one of the causes of death. This may suggest that a low BMI related to dysphasia associated with death and life prognosis. In our participants, the median BMI was 20.2 kg/m2; in few individuals with obesity, however, a higher BMI with better feeding status was associated with higher survival rates. Although previous studies on reverse epidemiology have not discussed the nutritional status of the elderly, dysphagia in older patients undergoing hemodialysis might be considered one of the appearances of reverse epidemiology. ” (Page 16, lines 5–16)

Regarding limitations, it is necessary to mention the limitation of the use of BMI and possibly the lack of an adequate parameter for more effective conclusions through the assessment of body composition and muscle function, whether strength or functional capacity of elderly individuals and its relationship with dysphagia.

Response: In the limitation part, we have emphasized the limitation of the utilization of the BMI as a parameter related to dysphagia as well as the necessity of using indicators that reflect body composition and muscle function. The added part is as follows:

“We used the BMI as a nutritional indicator related to dysphagia; however, we did not consider body fluid removal during the dialysis session. Therefore, the results did not reflect the body composition or edema status of patients. Additionally, as dysphagia is related to muscle capability, indicators reflecting muscle function should also have been considered.” (Page 20, lines 6–10)

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Decision Letter 1

Mabel Aoun

2 Dec 2022

Importance of feeding status evaluation in older patients undergoing hemodialysis

PONE-D-22-12985R1

Dear Dr. Kitamura,

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

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Reviewer #2: Yes

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Reviewer #1: (No Response)

Reviewer #2: I would like to congratulate the authors of the manuscript. As well as for the effort to solve my doubts, suggestions, and questions raised.

The only information that I was not able to identify in the revised version was the age adopted as a criterion for inclusion in the sample of elderly patients on hemodialysis. I think it's important for the reader.

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Reviewer #2: No

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Acceptance letter

Mabel Aoun

22 Dec 2022

PONE-D-22-12985R1

Importance of feeding status evaluation in older patients undergoing hemodialysis

Dear Dr. Kitamura:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

Dr. Mabel Aoun

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    Supplementary Materials

    S1 Data. Patients’ data are supplied in a supporting information file.

    (XLSX)

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    S1 Table. Association between major items of the Kuchikara Taberu Balance Chart and dementia.

    Wilcoxon sum rank test was used.

    (DOCX)

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    S2 Table. Association between major items of the Kuchikara Taberu Balance Chart and nutritional indicators.

    Spearman’s rank correlation coefficient was used.

    (DOCX)

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    Attachment

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