PONE-D-22-22497Changes in the prevalence of diabetes, prediabetes and associated risk factors in rural Baluchistan; a secondary analysis from repeated surveys (2002-2017)PLOS ONE

Dear Prof. Abdul Basit,

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.

Dear authors,

I commend that the topic of the paper is interesting, especially for the alarming increase in a rural population. However, my own reading raised a number of concerns which need to be addressed before any final decision is made. First, the Methods section needs clarification. For instance, it is not clear which outcomes were collected in three surveys and which ones were not. Instances are shown in Figure 1E and 1F where only two surveys are presented. Second, authors refer to "pooled prevalence", it seems that they just collapsed pre and diabetes categories? Third, the methods section is fuzzy the way it stands now. It is unclear which are the outcomes and associated factors in the paper. This section needs to reworked to reflect the standard of PLOS One. Third, this section is unclear regarding the sampling design in the three surveys, and how the sampling design was taken into account the estimations. Without this information or clarification, it is not possible for the readers to trust the estimates. Fourth, I wonder how readers could trust estimates from the 2001-2002 survey given tremendous differences with 2009-2010 and 2016-2017 surveys. The estimates from these surveys cannot be trusted without further explanations of these differences. What happened between 2001-2002 survey and subsequent surveys. I question what has changed in the Pakistani rural context to see such a shift in only 10 years. Usually, such changes are expected on long-run but short- or mid-run. As a consequence, most differences in percentage points between 2001-2002 and 2016-2017 are above 10 points and combined obesity, over 15 years, increased by 72 percentage points. This is impressive and questionable at same time (Table 2). Surprisingly, the Discussion section is silent about convincing explanation of this health catastrophe. This is where authors need to be more creative and build from their knowledge of the ground in the Pakistani context to explain to the readers what happened to explain these findings. Finally, my fears are consolidated by Table 3 where only a few variables showed statistical significance with the outcomes of the paper. Why?

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Kind regards,

Zacharie Tsala Dimbuene, Ph.D.

Academic Editor

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: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

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: 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: Diabetes is one of the biggest challenges for the public health and the number of people affected by this diseases still increases. There is still a big gap in diabetes management between high and low-income countries. It has been reported that approximately 80% of adults with diabetes worldwide live in low-income and middle-income countries.

Therefore, despite the fact that presented study comes from one region with small study group, I think it is valuable to present. Most pre-existing studies come from urban populations or high income countries, so in that way presented study adds to the existing evidence and helps to draw attention to the problem of diabetes in rural areas. In my opinion the article is well-written. I have some minor comments:

I think it would be helpful if overall number of participants was mentioned in the abstract and the methods section.

It is stated that “BMI <23 kg/m2 was considered as normal, ≥23-24.9 kg/m2 as overweight and ≥25 kg/m2 as obese”. The citation [19] at the end of the sentence doesn’t lead to the source of the criteria and they differ from the widely recognizable WHO norms. The reference should indicate the guidelines for BMI, if the Authors chose the norms for Asia-Pacific region, it should be clearly explained.

The abstract should be improved, as there are some nominal sentences.

Reviewer #2: In page 3, line 65, It is mentioned that population of Baluchistan (85% rural, 38% urban) which needs correction

In discussion, page 18, findings of tobacco consumption at national level like in NCDs survey [https://pubmed.ncbi.nlm.nih.gov/29658619/] and Global Adult Tobacco Survey [https://pubmed.ncbi.nlm.nih.gov/29059338/] may be discussed in detail that why it is different from general population.

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Reviewer #1: No

Reviewer #2: Yes: Dr. Ibrar Rafique

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Changes in the prevalence of diabetes, prediabetes and associated risk factors in rural Baluchistan; a secondary analysis from repeated surveys (2002-2017)

PONE-D-22-22497R1

Dear Dr. Basit,

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,

Zacharie Tsala Dimbuene, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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: (No Response)

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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: (No Response)

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 Response)

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: (No Response)

Reviewer #2: (No Response)

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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: Dr. Ibrar Rafique

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