PONE-D-21-34725The Contribution of Avoidable Factors in Doubling or Halving the Risk of HypertensionPLOS ONE

Dear Dr. Poorolajal,

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PLOS ONE

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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: No

Reviewer #2: Yes

Reviewer #3: Partly

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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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

Reviewer #3: 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: Introduction.

1. For clarity, the authors need to address what different forms of hypertension are.

2. Knowing how much more exposure to a factor can halve or double the risk of an outcome of interest is critical in public health policy because it allows for better prioritization and planning of prevention programs. While it is good to know the impact of each factor on the risk of hypertension, it can be hard to have an accurate estimate due to their complex interactions. For example, fruit and vegetable consumption can affect blood pressure by influencing blood glucose, BMI, etc.

3. “At the moment, only a few studies have been conducted to determine how much exposure to these well-known factors requires to halve or double the risk of hypertension”. Please list out what factors had been examined in 2 previous studies and briefly summarize the findings.

Methods

4. “A serving size is standardized to represent 80 grams of fruit and vegetable consumption.” How were subjects instructed on the serving size? Would they need to weigh the amounts? Did they have a scale at home?

5. “light-intensity activity is an activity that is classified as <3.5 kcal….” Would subjects know how to assess physical activities they performed as light, moderate, or vigorous? The authors need to provide more information.

Results

6. “The mean (SD) age of the participants was 44.50 (6.26) years with a range of 18 to 100 years” Science age is a risk factor for hypertension; more detailed information can be provided, such as median and IQR.

7. The prevalence of hypertension was 26.3% (7,842 out of 30,542). What is the prevalence in men and women?

8. “Based on the multiple logistic regression analysis, current daily cigarette smoking, alcohol consumption, dairy consumption, fish consumption, and high-density lipoprotein level had no significant association with hypertension.” More data on the factors shall be presented since they were reported to associate with blood pressure.

9. “burning of 7175 kcal through physical activity at work or recreation daily.” Will this level of physical activity be practical? If not, the authors may need to use a different OR that can generate an estimate applicable for policy generation.

10. “an increase in FBS of about 77 mg/dl, and an increase in total cholesterol of about 134 mg/dl.” The magnitude of FBS and TC seems not so clinically relevant. What is the OR when FBS is increased by 39 and TC by 67?

Discussion

11. “The evidence suggests that vegetables and fruits reduce blood pressure through various mechanisms.” The authors shall need to list out the mechanisms with citations.

12. “A similar study reported that every 10.3 unit increase in BMI or 50% increase in the waist-hip ratio can double the risk of hypertension “ Since the same group published the study of the reference 15, the authors need to elaborate the differences between 2 study cohorts or the data of the same cohort were used in the analysis.

13. “both of which result in renal tubular reabsorption, sodium accumulation, volume overload, and thus hypertension25-27” After this sentence, it would be great to add the information on how weight loss can decrease the risk of hypertension.

14. The authors need to enrich the discussion section by including more information on the factors identified in the present study and blood pressure in the literature.

Reviewer #2: This paper explored the relationship between fruit/vegetable consumption, physical activity, body mass index, waist-hip-ratio, fasting blood glucose and total cholesterol in Iran and halving or doubling the risk of hypertension. And obtained how much fruit/vegetable and physical activity halve the risk of hypertension and how much increase in body mass index, the waist-hip-ratio, fasting blood glucose, and total cholesterol can double the risk of hypertension. These results may be useful for developing guidelines.

Reviewer #3: This goal of this manuscript was to explore the cut-offs associated with a given odds of having hypertension. Data appeared to have been obtained from a large survey study. The value of such information is noted in such a large scale study population. A few comments to consider.

1) The analysis performed used logistic regression which models the "odds" of an event rather than the "risk" of an event. There is a difference between "odds" and "risk". Revise to match the analysis.

2) The phrase "replicate the odds ratio" is not clear. Consider revising. Possibly something like the target odds ratio?

3) The methods state that "All statistical analysis were performed at a 95% significance level...". This should likely state that all analyses were performed at the 2-sided 0.05 significance level (which corresponds to a 95% confidence level).

4) It may be beneficial to consider rephrasing the analysis that was performed so that is clearer. The goal appear to be, at what level of some continuous variable, does the odds reach a level of 0.5 (indicating the reduction on the odds of having hypertension) and 2.0 (an increase in the odds of having hypertension). The interpretation of the coefficient of the multiple regression model is assuming other factors are held constant, for every 1-unit increase in the continuous variable, the log odds of hypertension increases by xx. For fruit and veggies, a 1 unit increase in fruit/veggie consumption, the odds of hypertension is exp(-0.09263)= 0.91. Since this is on a continuous scale, a 7 unit increase in fruit/veggie consumption corresponds to an odds ratio of exp(-0.09263*7)=0.52. There is also variability associated with this estimate as is represented by the confidence interval of the model coefficient.

5) The discussion section states: "The replicated OR of 0.5 or 2.0 reported here for each variable was adjusted for other model variables, in the table. In other words, we used a multiple logistic regression model accounting for all other variables. Therefore, we were able to measure the pure influence of each variable on blood pressure regardless of the other variables in the model."

However, in multiple logistic regression, each estimated coefficient is the expected change in the log odds of hypertension for a unit increase in the corresponding variables, holding the other variables constant at a certain value. Please revise this sentence with respect to the use of multiple logistic regression.

6) Participants that were already on hypertension medication were coded to be in the "hypertension" group regardless of whether or not medication controlled their hypertension. How many subjects reported being on hypertension medication? This could potentially change the meaning of the modelled odds in that it is the odds of being hypertensive or being medicated for hypertension.

7) To look at factors associated with increased odds of hypertension, what would happen if you did a subgroup analysis of those participants not currently medicated for hypertension? Are results consistent?

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Reviewer #1: Yes: Oliver Chen

Reviewer #2: No

Reviewer #3: No

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Attachments

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Submitted filename: PONE-D-21-34725.docx

PONE-D-21-34725R1The Contribution of Avoidable Factors in Doubling or Halving the Odds of HypertensionPLOS ONE

Dear Dr. Poorolajal,

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 submit your revised manuscript by Apr 30 2022 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. When you're 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.

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). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Oliver Chen

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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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 #2: All comments have been addressed

Reviewer #3: 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 #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: 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: No

Reviewer #3: 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 #2: Yes

Reviewer #3: 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: Specific comments:

1. "Hypertension affects an estimated 1.13 billion people worldwide or nearly 15% of the world's population (1 in 4 men and 1 in 5 women)" in the article does not indicate the reference source.

2. Whether "fasting blood glucose, high-density lipoprotein and total cholesterol" were tested in the field or at a testing facility.

3. Whether people with hypertension were included in the group whose blood pressure was controlled through lifestyle change.

4. Which questionnaire was used for information collection, and whether the reliability and validity of the questionnaire have been verified.

5. It is suggested to update the references.

Reviewer #3: All comments have been addressed and the appropriate adjustments have been made to the manuscript. No further comments.

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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: No

Reviewer #3: No

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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.

The Contribution of Avoidable Factors in Doubling or Halving the Odds of Hypertension

PONE-D-21-34725R2

Dear Dr. Poorolajal,

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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Kind regards,

Oliver Chen

Academic Editor

PLOS ONE

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