PONE-D-19-27618

Relationship of sociodemographic and lifestyle factors and diet habits with metabolic syndrome (MetS) in a multi-ethnic Asian population

PLOS ONE

Dear Dr Iqbal,

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Hoh Boon-Peng, PhD

Academic Editor

PLOS ONE

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Authors should emphasise the implications based on the current findings, and the future direction of the study.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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

Reviewer #1: I Don't Know

Reviewer #2: Yes

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

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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 paper is well written highlighting the relevance of the study. The results were discussed in well and in detail. A minor suggestion would be to address a few grammatical errors and to suggest future research direction.

Reviewer #2: By using statistical test and multiple logistic regression, authors studied the association of multiple factors including sociodemographics, lifestyle, diet patterns with MetS of major ethnic populations in Malaysia. What is the potential clinical value of the finding to society in Malaysia?

Multiple grammatical errors were spotted and sentences are incoherent, it is strongly recommended to proof read the article by native speaker. Also, authors are advised to present the paper in reader friendly manner, for example tab indent at the beginning of new paragraph or newline insert between paragraphs.

Unclear conclusion with hanging sentences.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-19-27618R1

Relationship of sociodemographic and lifestyle factors and diet habits with metabolic syndrome (MetS) in a multi-ethnic Asian population

PLOS ONE

Dear Dr Iqbal,

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.

We would appreciate receiving your revised manuscript by Feb 24 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Hoh Boon-Peng, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Although sample size calculation was included, the issue on small sample size of this study remains a question. Authors could justify by showing the prevalence of MetS for each ethnicities, and the calculation of power of studies.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: (No Response)

Reviewer #4: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Partly

Reviewer #4: Yes

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

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

Reviewer #4: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

Reviewer #4: Yes

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6. 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 #3: The paper described a cross-sectional study of 481 participants on the association between metabolic syndrome and sociodemographic, lifestyle factors and diet habits. The authors collected data via questionnaire survey at 5 study sites in the state of Johor from 2016 to 2018. Based on the findings, the authors have concluded that three Malaysian ethnic groups are diverse in their sociodemographic, lifestyle factors and diet habits and therefore showed difference in the prevalence of MetS. In general, older age is highly associated with the prevalence of MetS; MetS is more and less prevalent to Indian and Chinese, respectively; higher education decreased the risk of developing MetS; and quick finishing of meals and low physical activity is associated with the development of MetS.

However, there is a major concern regarding the sample size and the interpretation of data in the paper. The total number of samples is 481 and when it was stratified into 3 ethnic groups, Malay, Chinese and Indian have the number of 147, 228 and 106, respectively. These sample sizes are too small and cannot be settled with valid and reliable results, especially for Table 3. The problem of small sample size is simply reflected on the wide 95% CI in Table 3 where the authors claimed that the higher age groups of Chinese and Indian were associated with MetS, low physical activity in Chinese and fast finishing meals in Malay were in favour of greater risk of MetS. As the 95% CI is extremely wide, it indicates the very weak association of variables with MetS despite the p value is less than 0.05. In addition, the method in calculating the sample size was not written in detail and also it is not clear how the estimated sample size was calculated for each ethnic group.

Another concern would be the variables studied by the authors. A few relevant variables are missing in the analysis. Among them, wealth/income index is the most relevant variable for the sociodemographic characteristics but it is not included in the analysis.

Some minor comments:

(1) The title of paper does not reflect the actual population that was studied. I would suggest to replace “a multi-ethnic Asian population” to “three ethnic groups of the Malaysian population” in the title.

(2) The study was taken place in Johor, however, no explanation of why Johor is selected in this study. Can the population in Johor be the representative of the nation?

(3) page 15, line 3 from the bottom of paragraph: “….41.6% at the age group of 40-49 years…..” Instead of 41.6%, it was 41.8% written in Table 1.

(4) page 24, line 4 from the top of paragraph: “Our results show the prevalence of MetS and its components to be comparatively lower among Chinese than in the Malays and the Indians, and this could be attributed to better lifestyle choices, including physical activity”. The sentence is overstated since there is not enough evidence to show Chinese have better lifestyle choices except the physical activity.

(5) The following references are similar studies and shall be mentioned in the paper:

- Kaur et al. (2018) Journal of Immigrant and Minority Health 20, 1380-1386.

- Narayanan et al. (2011) Metabolic Syndrome and Related Disorders 9, 389-395.

- Tan et al. (2011) Metabolic Syndrome and Related Disorders 9, 441-451.

Reviewer #4: The paper is well written; the significance of the study is clearly indicated. The results and discussion are adequately presented and described. However, some defining criteria of metabolic syndrome (page 12) are inaccurately written - the definitions of raised serum triglycerides and low HDL are missing the symbols of "equals to or more than"and "less than" respectively. The grammatical deficiency has been addressed immensely. However, isolated grammatical errors are still present including those listed below:

1)page 23; paragraph 2; line 1

2)page 24; paragraph 1; line 10

2) page 25; paragraph 2; line 6-7

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

Reviewer #4: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

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Relationship of sociodemographic and lifestyle factors and diet habits with metabolic syndrome (MetS) among three ethnic groups of the Malaysian population

PONE-D-19-27618R2

Dear Dr. Iqbal,

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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With kind regards,

Hoh Boon-Peng, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: