PONE-D-21-20970Sleeping Duration, Physical Activity and Alcohol Drinking as Potential Attributes of Metabolic Syndrome in Adults in EthiopiaPLOS ONE

Dear Dr. Mekonnen,

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.

 Five reviewers have reviewed your paper and made several excellent suggestions for improvement. Please pay specific attention to:

• Use of the central obesity measure and cut-offs, clarify, and add additional analyses using different cut-offs.
• Identification of U-shaped relationships should be based on the multivariable analysis. Looking at the adjusted ORs no U-shape relationships were identified though. If there are any U-shape relationships, please present them graphically using log odds or log odds ratio plots for dose - response non-linear continuous exposure.
• Better describe choice and definition of risk factors, as well provide more details about the study sites.
• Make sure to adhere to STROBE reporting guidelines for cross-section studies.
• Also note that reviewer 2 included the review of your paper as a separate Word document.

Please submit your revised manuscript by May 19 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.

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We look forward to receiving your revised manuscript.

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Bart Ferket

Academic Editor

PLOS ONE

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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: Yes

Reviewer #3: Partly

Reviewer #4: Partly

Reviewer #5: Yes

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: I Don't Know

Reviewer #4: Yes

Reviewer #5: 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

Reviewer #3: Yes

Reviewer #4: No

Reviewer #5: 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: No

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

Reviewer #5: 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: 1. The title: should be reconsidered. Looking at the line 235 of the manuscript, several factors are associated with the Metabolic syndrome .eg sex and age, yet the author chooses only a few for the title. They may consider "associated factors" without being specific.

2. Abstract: The conclusion on the abstract would need revision. in Line 44 the author uses the words " very emerging " which does not sound right given that we are not comparing it with any specific time in the past , to provide evidence of an increase.

3. Introduction: Would be useful to justify in a paragraph why the author chose a hospital population and not a community sample.

4. Methods: Line 101 need to be checked. The author says " simple random sample to catch up on the subjects" which does not sound very scientific.

Line 105: Why did the author choose WHO Steps survey, would help to describe this a bit more and provide reference.

Line 125 : What is " Ethiopia's adult classification System"

Define first terms the first time they appear, See FBD, HDL ( lines 131, 135).

Line 141 Give reference for General physical Questionnaire and report if it has been used previously in similar settings.

Line 156: Give reference for the food questionnaire

163: Justify the fact that the one question on sleep is adequate.

5. Discussion: include limitations of the study.

Reviewer #2: I have offered specific comments, please find attached review report. Thus, improving the clarity of the study’s reporting guidelines will, in my mind, undoubtedly increase its impact. The study design methodology is currently missing crucial information that should be pre-specified comprehensively and as far as possible in the abstract and methods section.

Reviewer #3: 1. Abstract: line 45 - " U " shaped relationships. Relationship for e.g between physical activity and MetS is not U shaped. Low, moderate and high physical activity - The prevalence of Mets is 45%, 27.5% and 13.2 % respectively. Similarly with sleep duration and education level

2. Inconsistent use of waist circumference cut -off values . Line 63-64 - 83.7 cm and 78 cm for males and females respectively - Authors use country specific WC cut off. However, Line 126- 127 , - Authors use IDF criteria 94cm and 80 cm respectively for males and females

3. Sleep categories inconsistent and incorrectly described . Lines 164 -165 - 4 categories noted ,However only 3 are described. Furthermore, the categories in Table 2 are not consistent with those described in the method (lines 164 -165 ), or in the publication that the authors use as a reference

4. Line 169 - Variables with a p value of less than 0.2 in the bivariate analysis were exported to the final model. Although I am aware that it is not incorrect to use this level of significance , can the authors please explain the rationale behind the use of this level of significance in this study.

5. Line 256 -this statement is not correct in two respects.

a. The results do not support this statement. The authors state that there was an inverse relationship between level of education and MetS. However, in Table 2 the prevalence of MetS is 20.1 % ,33.5% and 41.9 % in patients with no education, a high school level of education and a college education respectively

b. The publication referenced does not contradict this statement. Santos et al (reference 48) indeed reported an inverse relationship between educational level and the prevalence of MetS in their study

6. Table 1 -No currency for monthly income level categories

7. Table 2 - Poorly formatted.

8. Table 3 - "Consumption outside home " needs to be clarified.

9. Table 5 - The prevalence of MetS should be presented as n(%) ,not only n

10. An examples of a significant language error

lines 287- 289 : "However, the clear underlying mechanisms related to the relationship between shorter sleep duration and MetS are understood."

I believe the authors meant to say the underlying mechanisms between duration of sleep and MetS are not clear or well understood

Reviewer #4: This is a very important topic area, metabolic syndrome and its associated risk factors are required in SSA population. However, authors should consider the following suggestions.

1. I think the current title over exaggerates the study, because other risk factors of metabolic syndrome were looked at in the study, why is the author focusing on sleep duration, alcohol drinking and physical activity in the title.

2. Line 206, the author referenced table 4 twice, Table Four ….., S, and BP (Table 4). Please reword

3. The central obesity parameter that was used in this manuscript for African population might have over estimated or underestimated the prevalence among your population. The author have used .. waist circumference ≥83.7 64 cm for males and ≥78.0 cm for females. The harmonized definition suggested that 94 and 80cm should be used for SSA population (https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.109.192644?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed) . Also an optimal waist circumference cut-off for SSA population has been published by Ekoru et al, 2018(https://www.nature.com/articles/ijo2017240). I will suggest that the authors should re-analyse using either of this cut off.

4. Line 214 .. Aas one becomes aged the probability of having MetS increased as well. Please reword this sentence

5. Generally, I will suggest that the Author edits the manuscript or engage an editor to complete that role on their behalf.

6. Line 287 – 289 .. It seems that both the genetic and environmental factors causing MetS but 288 in this study, the environmental factors predominantly contributed to the rapid increment of 289 MetS and are fully subjected to modification given large-scale interventions are designed. I will suggest that the author should conclude the study following the focus of the variables that were collected, which in this instance are behavioural factors. The author has not collected r discussed any environmental factors for this study, so should not conclude

Reviewer #5: The metabolic syndrome is an increased public health issue particularly in low- and middle-income countries (as authors noted). It needs to be well described in both general population and specific population (like patients). The study is of important for both clinician and public health managers in Ethiopia to address MetS in all context.

Major comments

• Authors have noted (line 83-84) that “Previous studies conducted in Ethiopia have documented a high prevalence of MetS ». Thus, it is not clear why the study was conducted and which gap of knowledge it filled.

• Line 94-95: Study site was not described. Authors have to provide more details about the study site (is it a secondary of tertiary hospital? how many bed?, which department of hospital was targeted and why? How many outpatients attended by year? the hospital is located in rural or urban areas, etc.…)

• Line 99: it is not clear how the sample size was calculated and how the simple ramdom sampling was performed how the study design was considered in the data analysis. Can authors provide more information about this?

• I suggest that authors improve the presentation of the results of their study, mainly subsection about the MetS (line 198-207). Indeed, they have to describe the prevalence of MetS in a paragraph and the components of MetS in another paragraph. In addition, It is not clear why authors check for a correlation between WC and others MetS components since this was not cited as study objective. I recommend the authors to be focus on their study objective in the presentation of the results of their study.

• Authors have to provide limitations of their study since the study has many limitations. First, it was conducted in hospital and may not be considered to make inference to the general population of Ethiopia. The behavioral variables might be affected by social desirability bias.

• Authors has to provide more details of public health or clinical pratice implication of their study since it was done in health facility. e.g: to organize sensitization campaign targeting patients attended in hospital.

Minors comments

• I suggest that authors in the title of the manuscript precise the type of the study

• Line 56: Please, correct the abbreviation of metabolic syndrome “MetS” instead of “Mets”

• Line 63: Please, precise which definition of metabolic syndrome was provided here. It is not clear in the text.

• Line 68-69: authors had to indicate why they used the most recent definition (since it is also discussed)

• line 73 to 75: Please, provide the reference of the statement

• Line 133: the mean of (26) is not clear.

• Line 172: the acronym AOR was use for the first, it needs to be defined.

• Line 186-190: It is not clear if the prevalence of MetS reported in this paragraph is the history of MetS or MetS diagnosis during the current study. Please, can authors provide clarification?

• Line 214: correct Aas

• Table 3 line 1 : Please the number 3(0.7)

• Please improve the tables formatting

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Reviewer #1: No

Reviewer #2: Yes: Sphamandla Josias Nkambule

Reviewer #3: No

Reviewer #4: No

Reviewer #5: Yes: Kadari Cisse

[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.]

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Attachments

Attachment

Submitted filename: Evaluation Report - Manuscript Review Due 19 Feb 2022 PLOS ONE.docx

PONE-D-21-20970R1Sleeping Duration, Physical Activity and Alcohol Drinking as Potential Attributes of Metabolic Syndrome in Adults in Ethiopia:  A Hospital-Based Cross-Sectional Study.PLOS ONE

Dear Dr. Mekonnen,

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 revise the title as suggested by Reviewer 1, e.g., into: "Sleeping Duration, Physical Activity, Alcohol Drinking and Other Risk Factors as Potential Attributes of Metabolic Syndrome in Adults in Ethiopia: A Hospital-Based Cross-Sectional Study."
• Please revise the limitations and conclusions as suggested by Reviewer 1 as well.

Please submit your revised manuscript by Aug 21 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,

Bart Ferket

Academic Editor

PLOS ONE

Journal Requirements:

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

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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

Reviewer #2: Yes

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

Reviewer #1: Yes

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 #1: Yes

Reviewer #2: 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 #1: No

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 #1: Additional METS STUDY COMMENTS

1. I still feel the Title needs to be reflective of the content of the manuscript. Because the authors accepts that fact, they should coin a title that includes more than sleep, physical activity and alcohol.

2. Given that only one question was asked about sleep, I propose that this is captured as part of the limitations.

3. I appreciate the inclusion of the limitation section-the statement “ undoubtedly reproducible” on line 345 can be replace with more gentle statement like“ may be generalized..because….”

4. The last two sentences on the conclusion section do not sound appropriate They can be reworded to encourage not sound like a warning “Unless the national health policy for NCDs prevention is revised and effectively implemented, the developmental progress of the nation will be stepped backed due to the high health care expenditure, high disability adjusted life years and economic crisis. In general the global commitment designed targets in the Sustainable Development Goals will be off-track by 2030”

Reviewer #2: Thank you, for affording me the opportunity to review your work. This manuscript is a herculean effort and an enjoyable read. The study’s objectives are essential in understanding the prevalence of metabolic syndrome and patterns of attributable risk factors in adults.

Moreover, this topic is significant, considering the more ageing adult population’s unprecedented growth and the projected increase in the prevalence of metabolic syndrome globally. After rigorously reviewing the revised manuscript, the authors have adequately addressed my comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication.

Kudos, to the team!

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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 #1: No

Reviewer #2: Yes: Sphamandla Josias Nkambule

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[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.

Attachments

Attachment

Submitted filename: METS SSTUDY COMMENTS.docx

Sleeping Duration, Physical Activity, Alcohol Drinking and Other Risk Factors as Potential Attributes of Metabolic Syndrome in Adults in Ethiopia:  A Hospital-Based Cross-Sectional Study

PONE-D-21-20970R2

Dear Dr. Mekonnen,

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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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,

Bart Ferket

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: