PONE-D-21-37788Effect of comorbidities on health-related quality of life among adults with type 2 diabetes attending different hospitals in southern BangladeshPLOS ONE

Dear Dr. Mannan,

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Mohammad Farris Iman Leong Bin Abdullah, Dr Psych

Academic Editor

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Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: I Don't Know

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #1: Effect of comorbidities on health-related quality of life among adults with type 2 diabetes attending different hospitals in southern Bangladesh

Title: The title is misleading because there is an implication of the language of causality. Please rephrase the title to: “The relationship between medical comorbidities and health-related quality of life among adults with type 2 diabetes: The experience of different hospitals in southern Bangladesh”.

Overall comments:

The writing of the manuscript is good, with fair scientific merits based on the statistical methods employed. Having said that, there were some concerns of inference on the statistics of “correlation” when the author(s) mentioned that “The number of comorbidities was found to be negatively correlated with the HRQoL. “ Has any correlation study been employed in this research? The authors may change the wording of the sentences or employ the relevant statistics and discuss the findings.

Regarding the use of the statistical inference, please spell out OR as an odds ratio. The 95% CI was missing at each OR. Please insert it and standardise it through the text.

Specific comments:

Regarding abstract:

The abstract needs some revisions, as it contains the language of causality in the objective. The writing style was also required to be refined. I suggest some changes:

"Objective Health-related quality of life (HRQoL) is a critical determinant to assess the severity of chronic diseases like diabetes mellitus. It has a close association with complications, comorbidities, and medical aid. This study aimed to estimate the prevalence of medical comorbidities and determine the relationship between comorbidities and HRQoL among type 2 diabetic patients of southern Bangladesh. Method: This study was a cross-sectional study conducted through face-to-face interviews using a pre-tested structured questionnaire and by reviewing patient’s health records with prior written consent. The study was conducted on 2,136 patients with type 2 diabetes attending five hospitals of Chattogram, Bangladesh, during the tenure of November 2018 to July 2019. Quality of life was measured using the widely-used index of EQ-5D that considers 243 different health states and uses a scale in which 0 indicates a health state equivalent to death and 1 indicates perfect health status. The five dimensions of the quality index included mobility, self-care, usual activities, pain or discomfort, and anxiety or depression. Results: Patients with three comorbidities and with four or more comorbidities had a higher probability of reporting “extreme problem” or “some problem” in all five dimensions of the EQ-5D index compared with those without comorbidity (OR: mobility, 3.99, 6.22; usual activity, 2.67, 5.43; self-care, 2.60, 3.95; pain or discomfort, 2.22, 3.44; anxiety or depression, 1.75, 2.45). The number of comorbidities was found to be negatively correlated with the HRQoL. Conclusion: Prevalent comorbidities were found to be the significant underlying cause of declined HRQoL. To raise diabetes awareness and for better disease management, the exposition of comorbidities in regards to HRQoL of diabetic people should be considered for type 2 diabetes management schemas.”

Regarding Introduction. The introduction is fair. Please be mindful on the punctuation in the sentences. For example, there is a comma after “To our knowledge, this…. ” I suggest the term “To the best of our knowledge,”:

“To the best of our knowledge, this study pioneers in evaluating the relationship between HRQoL and 107 comorbidities using the EQ-5D-5L instrument in the type 2 diabetes population in the southern 108 regions of Bangladesh.” It should be ‘regions’ and ‘not region’.”

It was mentioned in line 76 and 77 that, “Apart from the economical standpoints, the mere existence of diabetes also takes a psychological toll on the individual diagnosed, due to this disease’s chronic manifestations and auxiliary clinical complications.” Please change “economical” to ‘economic”. Please consider the following references for this statement, which is currently without any citations.

Mohammad Farris Iman Leong Abdullah, Hatta Sidi, Arun Ravindran, Paula Junggar Gosse, Emily Samantha Kaunismaa, Roslyn Laurie Mainland, Norlaila Mustafa, Nurul Hazwani Hatta, Puteri Arnawati, Amelia Yasmin Zulkifli, Luke Sy-Cherng Woon. How Much Do We Know About the Biopsychosocial Predictors Glycaemic Control? Age and Clinical Factors Predict Glycaemic Control, But Psychological Factors Do Not. J Diabetes Res. 2020; 2020: 2654208. Online 2020 May 1. doi: 10.1155/2020/2654208

Luke Sy-Cherng Woon, Hatta Sidi, Arun Ravindran, Paula Junggar Gosse, Roslyn Laurie Mainland, Emily Samantha Kaunismaa, Nurul Hazwani Hatta, Puteri Arnawati, Amelia Yasmin Zulkifli, Norlaila Mustafa, Mohammad Farris Iman Leong Abdullah. Depression, anxiety, and associated factors in patients with diabetes: evidence from the anxiety, depression, and personality traits in diabetes mellitus (ADAPT-DM) study. BMC Psychiatry. 2020; 20: 227. Online 2020 May 12. doi: 10.1186/s12888-020-02615-y

Luke Sy-Cherng Woon, Roslyn Laurie Mainland, Emily Samantha Kaunismaa, Paula Junggar Gosse, Arun Ravindran & Hatta Sidi. What makes poor diabetic control worse? A cross-sectional survey of biopsychosocial factors among patients with poorly controlled diabetes mellitus in Malaysia. Int J Diabetes Mellitus in Dev Countries. 2021. DOI: 10.1007/s13410-020-00918-0

Regarding methods: The methods are okay, except for the missing sampling strategy. Is there any cluster and stratified sampling performed for the two southern hospitals in Bangladesh?

Please do a correlation (Pearson/Spearman) study between all medical comorbidities and the measuring scales for quality of life.

Regarding results. The Tables are self-explanatory and relevant.

Regarding discussion. Please avoid the language of causality in your discussion as the study performed was cross-sectional.

The first paragraph stated, “Patients with diabetes mellitus go through various degrees of HRQoL because of the chronic 308 nature of the disease and different levels of compliance followed over time. HRQoL deteriorates 309 significantly if they suffer from multiple comorbidities along with diabetes compared to the 310 patients who didn’t have any comorbidity.” Based on your literature findings and clinical experience, what would the factors associated with poorer HRQoL and multiple medical comorbidities besides the confounding effect of all oxidative diseases? Could it be a personality factor? Or any comorbidities with severe mental health problems?

Luke S Woon, Hatta Sidi, Norlaila M. Factor structure of the Malay-version Generalized Anxiety Disorder-7 (GAD-7) Questionnaire among Patients with Daibetes Mellitus. Med and Health. June 2020: 15(1): 208 - 217.

Reviewer #2: Study on effects of comorbidities on health-related quality of life among type 2 diabetes mellitus patients is an important area of research in diabetes care. However, there are few queries that need to be addressed by the authors.

1. Were all the adults type 2 diabetes mellitus patients attending the

in patients department and out patients department of the selected public and private hospitals recruited for the study?

2. How was the sample size of 2136 diabetes patients determined?

3. How were the types of comorbidities included in the study arrived at?

4. Though as mentioned in the manuscript that “the principal aim is to investigate impact of comorbidities based on their number and nature”, there is no finding on the impact of different comorbidity or nature of comorbidity.

5. Similarly, there is no finding on the different multimorbidity pattern in the manuscript, though it is one of the objectives.

6. Model 1 and Model 2 need to be mentioned.

7. Questionnaire used in the study for demography and comorbidity assessment maybe uploaded.

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Reviewer #1: Yes: Hatta Sidi

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Effect of comorbidities on health.docx

PONE-D-21-37788R1The relationship between medical comorbidities and health-related quality of life among adults with type 2 diabetes: The experience of different hospitals in southern BangladeshPLOS ONE

Dear Dr. Mannan,

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 PM. 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,

Mohammad Farris Iman Leong Bin Abdullah, Dr. Psych

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 #1: All comments have been addressed

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 #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

**********

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 #1: Yes

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 #1: Yes

Reviewer #2: 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 #1: There was an improvement in the writing and the presentation of the revised manuscript. However, some comments need to be addressed, and further edits are necessary.

For the discussion, it was stated that: "Patients with diabetes mellitus go through various degrees of HRQoL because of the chronic nature of the disease and different levels of compliance followed over time." These sentences are incomplete. Is it low or high HRQoL? For " HRQoL deteriorates significantly if they suffer from multiple comorbidities along with diabetes compared to the 331 patients who didn’t have any comorbidity." , I think the study does not have enough evidence to lead to a conclusion on the cause and effect, i.e., chronic disease lead to a low HRQoL, and vice-versa. The bilateral correlation must be discussed in depth. For example, people with low HRQoL may neglect their health and medication, leading o further deterioration of their blood sugar levels and other chronic medical problems (hyperlipidemia, obesity, etc.).

The discussion on the recommendation for intervention was also inadequate and needed elaboration. For example, how those affected individuals may improve their quality of life besides taking medication? What food is necessary to improve blood sugar and cholesterol level. How about a high fiber diet and some vegetables like ladyfinger and a low glycemic index food.

Reviewer #2: All the comments raised were satisfactorily addressed by the authors. No further query raised by this reviewer.

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Reviewer #1: No

Reviewer #2: Yes: Sandipana Pati

[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.

The relationship between medical comorbidities and health-related quality of life among adults with type 2 diabetes: The experience of different hospitals in southern Bangladesh

PONE-D-21-37788R2

Dear Dr. Mannan,

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.

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Kind regards,

Mohammad Farris Iman Leong Bin Abdullah, Dr Psych

Academic Editor

PLOS ONE

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Reviewers' comments:

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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 #1: 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 #1: Yes

**********

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

Reviewer #1: 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 #1: 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 #1: 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 #1: All comments have been addressed by the authors. Improvements have been performed in the discussion part.

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Reviewer #1: No