PONE-D-23-19169Lifestyle behaviours and associated factors among people with type 2 diabetes in Ningbo, China: A cross-sectional studyPLOS ONE

Dear Dr. Chattopadhyay,

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 Sep 15 2023 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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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.

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We look forward to receiving your revised manuscript.

Kind regards,

Hidetaka Hamasaki

Academic Editor

PLOS ONE

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Additional Editor Comments:

Dear authors,

Thank you for submitting your valuable work to PLOS ONE. Your research appears to have been ethically conducted and scientifically valid; however, the reviewers require you to make major revisions.

In addition to the reviewers' comments, the editor thinks that the authors should describe the sampling method used in this study and discuss potential biases in the manuscript.

I look forward to reading your revised manuscript soon.

Sincerely,

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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: Partly

Reviewer #2: Partly

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

Reviewer #1: N/A

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: The results of the present study may be meaningful for the study participants. However, I have some comments on the study.

Line 66-68: The study participants were selected from single hospital, which indicated that the study participants can not represent the status of the total T2DM patients living in Ningbo. In other words, I considered that there may be serious and uncontrolled representativeness bias in the present study.

Line 74: The diagnostic criteria of T2DM should be described in the text. Is there difference between diagnostic criteria of T2DM of China and of IDF / ADA? If there is, then why?

Line 88-89: The authors should clearly describe if there were study participants whose two readings were significantly different, and the significant difference should also be defined. If there were, then the measurement may be untrusted and that patient should be excluded.

Line 101-103, table 1 and 2: I suggest that waist-to-height ratio (WHtR) should be used to define abdominal obesity because waist circumference alone did not take differences in height into account. At least, the associations of WHtR with lifestyle behaviours and associated factors should be researched in the present manuscript.

Line 136: The study should include information on duration of smoking cessation in those ex-smokers. Actually, the years immediately following smoking cessation may represent a time of increased risk for DM (PMID: 34964876).

Line 207-208: It is difficult to exactly assess the intensity of physical activity (PA). The present study obtained PA data using IPAQ questionnaire (Line 109). I guess there may be another reasons: for example, the authors should describe if there was difference in education level between rural and urban participants in the results section. If education level of rural participants was lower than their urban counterparts, than the reliability of their IPAQ questionnaire results may be lower because of lower ability to understand and/or patience.

Line 233-241: The association between alcohol drinking and DM should be discussed in more detail. Moderate alcohol intake had minimal detrimental effects on long-term blood glucose management (PMID: 26294775). Furthermore, though the authors of a recent published study (PMID: 37414658) speculated that the emerged discomfort reduced alcohol consumption frequency in DM population of China, that frequency was not significantly associated with DM risk.

Line 264-265: Though that may be the first study “in a cohort of patients living with T2DM in Ningbo”, I still considered that the innovativeness of the present study is quite limited. As the authors mentioned, Ningbo ist an economically developed city in the eastern, coastal province of Chekiang (Line 47), however, I don't understand why the authors selected Ningbo as the studied city. The status of the city can not represent the most developed regions of China, and that city may not even represent the province of Chekiang. Furthermore, as above-mentioned, the study participants of the present study can not represent the status of the total T2DM patients living in Ningbo. Therefore, I considered that the present study may be only beneficial to those 806 study participants, and other T2DM patients may not benefit from the present study. The authors should clearly explain the innovativeness of the present study and the representativeness of the sample.

Line 269-281: There were some other limitations that the authors should mention in the text. For example, the cause and effect relationship can not be examined in the present cross-sectional study.

Line 276-278: I still considered that the present study only provides information in those 806 study participants because they can not represent the status of the total T2DM patients living in Ningbo.

Line 284-285: Again, the prevalence found in the present study was not the prevalence amongst T2DM patients in Ningbo, but just the prevalence amongst those 806 study participants.

Reviewer #2: This paper presents a cross sectional study on a descriptive analyses of life style risk factors and their associated factors in Ningbo, China. I have some concerns regarding selection bias due to the unexpectedly high prevalence of healthy diet and physical activity among the sample of individuals with type 2 diabetes, as this disease is strongly a lifestyle dependent disease. The authors attempted to discuss the unexpected result, but the aspect of selection bias was missing in the discussion and the limitations.

- How did you address selection bias?

- How were the participants asked to join the study? Were there any incentives?

- How was the response rate? It could very well be that those who accepted to participate are the ones who are more aware of their health. This is especially relevant because anthropometric measurements were taken, which would be uncomfortable for overweight or obese individuals.

- Is it possible to perform a non-responder analysis? This might also help understand the results of the study

- Did the questionnaire also include question on complications and comorbidities? If no, why, and if yes, why were they not considered in the analysis as they are highly relevant (for example by stratifying the sample by morbidity level)?

- Why were the extent of smoking and alcohol (for example number of cigarettes per day or frequency of alcohol intake) not considered?

The study would have a potential for being worth publishing, but only after addressing the issue of selection bias by adding justifications for example, and by including the response rate and reflecting on it.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-23-19169R1Lifestyle behaviours and associated factors among people with type 2 diabetes attending a diabetes clinic in Ningbo, China: A cross-sectional studyPLOS ONE

Dear Dr. Chattopadhyay,

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.

==============================

ACADEMIC EDITOR:Thank you for submitting the revised version of your manuscript.Reviewer#2 has recommended rejecting your manuscript; however, the editor believes that the authors have appropriately addressed the issue regarding the sampling bias and mentioned its limitation in the revised manuscript. Therefore, the editor requires you to make minor revisions based on Reviewer#1's comments.I look forward to reading your refined manuscript.  

==============================

Please submit your revised manuscript by Oct 14 2023 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,

Hidetaka Hamasaki

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: (No Response)

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: (No Response)

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

Reviewer #1: N/A

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: Yes

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: Most answers were reasonable. However, I considered that there are still some comments which the authors should response.

Comment #3: Lines 140-142: The authors should clearly define the implausible value in the revised manuscript.

Comment #7: The pages of reference #38 were volume 33 issue 9 1693-1701, but not S0939-4753(23)00091-1.

Comment #8: I agree that the present findings worth reporting and sharing after the phrase changed to “people living with T2DM attending a diabetes clinic…”. I suggest the authors provide more information on that diabetes clinic (i.e. the first affiliated hospital of Ningpo University), to explain why that clinic, but not other clinic, was chosen as the studied clinic. For example, if the first affiliated hospital had the best medical and diagnostic facilities for T2DM in Ningpo, or not?

Moreover, there were some other suggestions. First, the authors should carefully check the content of manuscript to avoid minor errors, for example, the above-mentioned reference #38 and the reference order. Second, it would be better if the DOI of all references were listed.

Reviewer #2: Even though the authors did a good job in the analyses and writing the manuscript, the study appears to have serious potential selection bias that was not addressed properly during the sampling phase. Data essential for calculating response rate and performing a basic non-responder analysis is not available, and this cannot be neglected especially that as the authors also explain, the sample is not representative and the generalisability of the data is very limited. In fact, I also doubt the generalisability of the data to the specific diabetes centre in Ningbo where the sample was recruited, since no information what so ever exists on non-responders. Therefore, I have problems in trusting the results of the study. In addition, no convincing justification is provided as to why the study was done using this specific diabetes centre (a collaborative partnership with the hospital is not a sufficient justification), so that I am not pretty sure what the results of this study would add to the literature, or whether the results are worth publishing. Therefore, I would unfortunately not recommend accepting the paper for publication.

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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: 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.

PONE-D-23-19169R2Lifestyle behaviours and associated factors among people with type 2 diabetes attending a diabetes clinic in Ningbo, China: A cross-sectional studyPLOS ONE

Dear Dr. Chattopadhyay,

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 Dec 01 2023 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,

Hidetaka Hamasaki

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.

[Note: HTML markup is below. Please do not edit.]

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: (No Response)

Reviewer #3: (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: (No Response)

Reviewer #3: Yes

**********

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

Reviewer #1: (No Response)

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 #1: (No Response)

Reviewer #3: No

**********

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 #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 #1: Lines 72-73: I guess that the authors may misunderstand my previous suggestion to provide more information on the diabetes clinic. The purpose of that suggestion is to clarify the representativeness of the present sample. If the present sample can not represent those T2DM patients living in Ningpo, or even not represent all T2DM patients attending that diabetes clinic, then I considered that the present study may be suitable for publication in some other forms, but not in the form of Research Article, though the findings worth sharing.

If possible, I suggest inviting a statistical editor to assess whether the present sample can represent the studied population. I have no more comments on the present manuscript and I considered that it may be more suitable if the decision (accept or reject) was made by that statistical editor.

Reviewer #3: Here is a list of specific comments. Note: line and page numbering in reviews and comments is based on ruler applied in Editorial Manager-generated PDF.

1. Page 7, line 143: “Researchers” seemed vague. I suggest listing initials of those responsible for the data cleaning to provide credibility.

2. Page 7, line 149: I suggest including the R package where the PropCIs function comes from.

3. Page 7, line 150: I suggest replacing “multivariate” with ‘multivariable.’

4. Page 7, lines 157–158: Why can’t the waist-to-height ratio be considered as one of the covariate? It did not seem necessary to include it as a sensitivity analysis.

5. Page 17, lines 261–262: I suggest paying less attention on the odds ratio of gender and smoking. There were too few females who were current smokers. Therefore, the estimates might not be reliable.

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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 #3: 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.

Lifestyle behaviours and associated factors among people with type 2 diabetes attending a diabetes clinic in Ningbo, China: A cross-sectional study

PONE-D-23-19169R3

Dear Dr. Chattopadhyay,

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,

Hidetaka Hamasaki

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Kudos to the authors for revising their work. Thank you for your effort. I believe that you have adequately addressed the issues raised by the reviewers. Celebrate this achievement, and good luck with your next endeavor!"

Reviewers' comments: