The impact of COVID-19 on the physical activity and sedentary behaviour levels of pregnant women with gestational diabetes

Medbh Hillyard; Marlene Sinclair; Marie Murphy; Karen Casson; Ciara Mulligan

doi:10.1371/journal.pone.0254364

Peer Review History

Original SubmissionNovember 13, 2020
13 Jan 2021 Decision Letter - Edward Mullins, Editor PONE-D-20-35725 The impact of COVID-19 on the physical activity and sedentary behaviour levels of pregnant women with gestational diabetes. PLOS ONE Dear Dr. Hillyard, 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. Please respond to the reviewer comments and to my queries in your response. Please submit your revised manuscript by Feb 27 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. 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We will update your Data Availability statement to reflect the information you provide in your cover letter. Additional Editor Comments: Thank you for this article, addressing an important issue in a group of women whose pregnancies are more complicated and in whom PA can make a great differenc in glycaemia and potentially perinatal outcomes. Please note the reviewer comments and address these. Additional comments: Please edit and focus the introduction which is rather long at present. Educational qualifications - suggest amend to indicate highest qualification gained as the results are not interpretable at present. Note that reason for increased exercise during pandemic was largely attributed to nice weather - now in winter, we are likely to be seeing lower levels of outdoor and overall PA in this group during lockdown. How would you advise researchers to address the issue of responder bias and the difficulty in getting an ethnically representative sample for this sort of study in future? [Note: HTML markup is below. Please do not edit.] 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 ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: No Reviewer #2: Yes ****** 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: No Reviewer #2: No ****** 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: Yes ****** 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: Many thanks for asking me to review this qualitative analysis examining the impact of Covid-19 lockdowns on the physical activity behaviour of women whose pregnancies are complicated by gestational diabetes. While this represents an important piece of work further and adds to the public health impact that lockdowns have, there are comments that need to be addressed prior to considering publication. Major comments: 1. Tables. In general they are difficult to follow. More explanation needs to be provided as to the parameters included in the tables and relevance of statistical analyses needs to be considered: i) Table 1: the column headings are misleading – I would suggest maternal demographics rather than age for the first column. Why are both range of age and mean values included? Are the data normally distributed? The inclusion of the p value for level of qualification suggests that a chi squared table for all categories has been generated? Was a bonferroni correction applied? It may be better to consider calculating the p value on two simple categorical alone eg qualifications vs no qualifications, and/or higher degree versus no higher degree as the number of variables included in the current analysis renders a high probability that the statistical significance could be related to chance. The same comment applies to table 2 and treatment for GDM. i) Tables 3 and 5: these tables are confusing and the headings need explanation 2. Lines 276-280: The mean gestational age of women in the sample is 22.1 weeks. The mean GA that women were diagnosed with GDM is 24.1 weeks. Do the authors have a comment on this discrepancy? The mean age does suggest that a significant proportion did not have an index pregnancy complicated by GDM given the time frame at which NICE recommends testing for this. Were women with T1DM/ T2DM perhaps inadvertently included? 3. Discussion: caution needs to be exercised in terms of over-stating the results. While the results indicate that women’s levels of activities dropped during covid, these are questionnaires asking women about past behaviours i.e. recall bias needs to be considered. Furthermore, at what point were women taking “pre-covid times”? Would this potentially not have included much earlier gestational age when physical activity would have been much less limited? Minor comments: 1. Lines 77-79 are not clear: do the authors mean “reported cases of severe covid”? 2. Line 113: Statement is narrow. Women of other non-white European ethnic groups such as Arab/ South East Asian/ Hispanic/ Black African Caribbean are also at risk of developing gestational diabetes. 3. Lines 139-141: evidence already explained earlier in the text therefore does not need to be repeated. 4. Power calculation for sample size: what outcome was the power calculation based on and what statistical analysis was used to reach the sample size? 5. Lines 297- 308: are all the questions that women were asked included in this section? Would it perhaps be better to include the actual questionnaire for clarity? If not feasible within the main text, perhaps in the supplementary information? 6 Line 292: This statement is confusing. Do the authors mean that x proportion of women adhered to PA guidelines according to the results of the questionnaire? Or is the statement inferred from the mean number of days that women exercised for over 30 minutes? If the latter, how they arrived at the calculation needs to be explained. 7. Line 376/377. This is not necessary to include. If women say they are more sedentary it would follow that they are likely to be less physically active 8. Lines 340-343. Proportions here are of more value than reporting “x Reviewer #2: It is a relevant research that investigates the relationship between the level of physical activity in pregnant women during the pandemic. It identifies a trend towards a reduction in physical activity levels during the pandemic and the lockdown enforced by the Government among pregnant women with Gestational diabetes. Physical activity tends to reduce for pregnant women as pregnancy progresses due to the physiological changes of pregnancy. How this observation affected their results was not clearly addressed in either the introduction or the discussion sections of the manuscript. The introduction is a bit too expansive and can be modified to become more concise based on the stated aims and objectives of the research. The research design and statistical analysis is appropriate. Also, the use of online platforms to share the research questionnaire is acceptable due to concerns about the pandemic. ****** 6. 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 #1: No Reviewer #2: 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.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0254364.r001
Revision 1
19 May 2021 Author Response RE: “The impact of COVID-19 on the physical activity and sedentary behaviour levels of pregnant women with gestational diabetes.” Response to Reviewers 27th April 2021. Reviewer’s comments Response Please edit and focus the introduction which is rather long at present Introduction has been edited and reduced in length Educational qualifications - suggest amend to indicate highest qualification gained as the results are not interpretable at present. Changed to degree/no degree How would you advise researchers to address the issue of responder bias and the difficulty in getting an ethnically representative sample for this sort of study in future? Suggestions added Section 6: strengths and limitations Table 1: the column headings are misleading – I would suggest maternal demographics rather than age for the first column. Why are both range of age and mean values included? Are the data normally distributed? Table simplified. Maternal characteristics heading added to first column. Range removed. It may be better to consider calculating the p value on two simple categorical alone eg qualifications vs no qualifications, and/or higher degree versus no higher degree as the number of variables included in the current analysis renders a high probability that the statistical significance could be related to chance. The same comment applies to table 2 and treatment for GDM. Table simplified. Changed to degree/no degree. P value given between the two categories. Table 2 GDM management changed to diet/medication Tables 3 and 5: these tables are confusing and the headings need explanation Tables simplified and headings for tables 3 and 5 explained Lines 276-280: The mean gestational age of women in the sample is 22.1 weeks. The mean GA that women were diagnosed with GDM is 24.1 weeks. Do the authors have a comment on this discrepancy? In line with the NICE guidelines (NG3) women who have previously had GDM should be offered early self monitoring of blood glucose or a 75g 2h Oral Glucose Tolerance Test as soon after booking as possible. Therefore these results suggest a larger number of women in the sample had GDM in a previous pregnancy and were therefore diagnosed earlier than the 24-28 week standard OGTT. This is in keeping with the fact that 62% of the sample were multiparous. Discussion: caution needs to be exercised in terms of over-stating the results. While the results indicate that women’s levels of activities dropped during covid, these are questionnaires asking women about past behaviours i.e. recall bias needs to be considered. Furthermore, at what point were women taking “pre-covid times”? Would this potentially not have included much earlier gestational age when physical activity would have been much less limited? It has been highlighted in section 6 Strengths and limitations that self-reporting and reliance on recall can result in inaccuracies. In addition, it has been highlighted that as women were self-reporting activity levels at both time points reporting inaccuracies are likely to be non-differential and therefore not affecting the general level of decline seen. In addition, the PA levels by trimester have been added to section 3.2 physical activity levels, showing that PA levels were lower in T1 and increased in T2. Lines 77-79 are not clear: do the authors mean “reported cases of severe covid”? Removed Line 113: Statement is narrow. Women of other non-white European ethnic groups such as Arab/ South East Asian/ Hispanic/ Black African Caribbean are also at risk of developing gestational diabetes. Line 149-150 made broader Lines 139-141: evidence already explained earlier in the text therefore does not need to be repeated. Earlier evidence/explanation removed to avoid repetition Power calculation for sample size: what outcome was the power calculation based on and what statistical analysis was used to reach the sample size? The outcome the power calculation was based on was the number of women diagnosed with GDM. There were 731,213 births in the UK in 2018. It is estimated that approximately 4.4% of women in the UK have GDM. This would mean approximately 32,173 women are diagnosed with GDM annually in the UK. Based on a power calculation with a population size of 32,173, at a 95% confidence level and 5% error, it was calculated that 380 women would need to complete the survey to provide representative results. Lines 297- 308: are all the questions that women were asked included in this section? No this is not all the questions which were asked but the questions relevant to this analysis. Line 292: This statement is confusing. Do the authors mean that x proportion of women adhered to PA guidelines according to the results of the questionnaire? Or is the statement inferred from the mean number of days that women exercised for over 30 minutes? If the latter, how they arrived at the calculation needs to be explained. Further explanation to how the percentage was arrived at is given. Line 376/377. This is not necessary to include. If women say they are more sedentary it would follow that they are likely to be less physically active Sedentary time and PA are two different behaviours. An individual can have increased their sedentary time but also have increased with PA, therefore looking at both of these behaviours separately is important. Lines 340-343. Proportions here are of more value than reporting “x Proportions are given in the original manuscript Physical activity tends to reduce for pregnant women as pregnancy progresses due to the physiological changes of pregnancy. How this observation affected their results was not clearly addressed in either the introduction or the discussion sections of the manuscript. Information on PA levels during each trimester has been included in section 3.2 The introduction is a bit too expansive and can be modified to become more concise based on the stated aims and objectives of the research. Introduction has been edited and made more concise. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0254364.r002
28 Jun 2021 Decision Letter - Edward Mullins, Editor The impact of COVID-19 on the physical activity and sedentary behaviour levels of pregnant women with gestational diabetes. PONE-D-20-35725R1 Dear Dr. Sinclair, 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. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. 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. Kind regards, Edward Mullins Academic Editor PLOS ONE Additional Editor Comments (optional): Many thanks for revising your manuscript. I think this will be a useful contribution to care for women with GDM. 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 #2: All comments have been addressed ******** 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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: 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 #2: Yes ****** 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 #2: Yes ****** 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 #2: I have no further comments. The queries I highlighted in my previous review have been addressed in this revised manuscript. The introduction has been reduced and is more focused in its present form. I note also the corrections made under the results section including information comparing PA levels during each trimester has been included in section 3.2, Also, a statement that the full questionnaire and data sets are available online has been added. ****** 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 #2: Yes:** Dr Michael Chudi Ezeanochie https://doi.org/10.1371/journal.pone.0254364.r003
Formally Accepted
13 Aug 2021 Acceptance Letter - Edward Mullins, Editor PONE-D-20-35725R1 The impact of COVID-19 on the physical activity and sedentary behaviour levels of pregnant women with gestational diabetes. Dear Dr. Sinclair: 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. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Edward Mullins Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0254364.r004

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