Sociodemographic and behavioral factors associated with diet quality among low-income community health center patients with hypertension

Jessica Cheng; Katherine C. Faulkner; Ashlie Malone; Kristine D. Gu; Anne N. Thorndike

doi:10.1371/journal.pone.0299781

Peer Review History

Original SubmissionFebruary 23, 2024
1 Jul 2024 Decision Letter - Habiba I. Ali, Editor PONE-D-24-06116Sociodemographic and Behavioral Factors Associated with Diet Quality among Low-income Community Health Center Patients with HypertensionPLOS ONE Dear Dr. Cheng, 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 Aug 15 2024 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. 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The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Thank you for stating the following financial disclosure: “Research reported in this publication was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number T32HL098048 (Cheng) and K24 HL163073 (Thorndike) and the National Institute of Diabetes and Digestive and Kidney Diseases under Award Number R01 DK124145 (Thorndike) and T32DK007028 (Gu). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.” Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. 3. In the online submission form you indicate that your data is not available for proprietary reasons and have provided a contact point for accessing this data. Please note that your current contact point is a co-author on this manuscript. According to our Data Policy, the contact point must not be an author on the manuscript and must be an institutional contact, ideally not an individual. Please revise your data statement to a non-author institutional point of contact, such as a data access or ethics committee, and send this to us via return email. Please also include contact information for the third party organization, and please include the full citation of where the data can be found. 4. 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. Additional Editor Comments: Please address the reviewer's comments. [Note: HTML markup is below. Please do not edit.] 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 ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 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 ****** 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 ******** 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: Summary In this study, authors used data from LiveWell observational cohort to identify the most important sociodemographic and behavioural factors related to the diet quality of low-income adults. Diet was assessed using 2x self-administered 24-h dietary recalls (ASA24) and the HEI-2020. Authors found that the most important factors associated with lower HEI-2020 were house ownership, male, tobacco use, marijuana use, and skipping meals. Strength of this study includes dietary assessment instrument and explicit/clear description of the HEI-2020 score calculation (ie, population ratio and simple scoring), comprehensive data collection and consideration of participants from hardly reached communities. I congratulate authors for their work. I only have minor comments. Minor The modelling approach and the underlying data are not adequate to confirm causal relationships, which is fine in the context of this descriptive study and adequately mentioned in limitations (L309). However, readers may be tempted to interpret findings as if acting on any factors would necessarily lead to health/diet improvements. I suggest authors further add a statement about this issue rather than only in limitations. In other words, I think it is relevant to remind readers how findings should be (correctly) interpreted early in the discussion. L168. Please indicate how many bootstrap samples were used and the specific method (i.e., normal approximation or percentile bootstrap)? L187-190. Proportion of missing data: to be consistent with the STROBE reporting checklist item 14 (Vandenbroucke et al., 2007), please add a table that indicates the number of participants with missing data for each variable of interest. Interpretation (ie, L250). An HEI score of 63 is higher than mean scores typically reported in NHANES. For example, 56.6 was the mean score reported by (Reedy et al., 2018). I acknowledge there is room for improvement, but it does not seem entirely accurate to state that diet quality is not aligned with guidelines. Code sharing. I recommend authors make the analytic code available in supplemental material or in a code repository. References Reedy, J., Lerman, J. L., Krebs-Smith, S. M., Kirkpatrick, S. I., Pannucci, T. E., Wilson, M. M., Subar, A. F., Kahle, L. L., & Tooze, J. A. (2018). Evaluation of the Healthy Eating Index-2015. J Acad Nutr Diet, 118(9), 1622-1633. https://doi.org/10.1016/j.jand.2018.05.019 Vandenbroucke, J. P., von Elm, E., Altman, D. G., Gotzsche, P. C., Mulrow, C. D., Pocock, S. J., Poole, C., Schlesselman, J. J., Egger, M., & Initiative, S. (2007). Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. PLoS Med, 4(10), e297. https://doi.org/10.1371/journal.pmed.0040297 ******** 6. 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 ******** [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". 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Revision 1
25 Jul 2024 Author Response Journal requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf Response: The files are now formatted and named as per journal requirements, 2. Thank you for stating the following financial disclosure: “Research reported in this publication was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number T32HL098048 (Cheng) and K24 HL163073 (Thorndike) and the National Institute of Diabetes and Digestive and Kidney Diseases under Award Number R01 DK124145 (Thorndike) and T32DK007028 (Gu). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.” Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. Response: Please use the following updated statement: Research reported in this publication was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number T32HL098048 (Cheng) and K24 HL163073 (Thorndike) and the National Institute of Diabetes and Digestive and Kidney Diseases under Award Number R01 DK124145 (Thorndike) and T32DK007028 (Gu). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. 3. In the online submission form you indicate that your data is not available for proprietary reasons and have provided a contact point for accessing this data. Please note that your current contact point is a co-author on this manuscript. According to our Data Policy, the contact point must not be an author on the manuscript and must be an institutional contact, ideally not an individual. Please revise your data statement to a non-author institutional point of contact, such as a data access or ethics committee, and send this to us via return email. Please also include contact information for the third party organization, and please include the full citation of where the data can be found. Response: Please contact the Massachusetts General Hospital Institutional Review board via email at partnersirb@partners.org to access data. 4. 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. Response: We have reviewed all references for accuracy and have made no changes. Additional Editor Comments: Please address the reviewer's comments. Response: We thank the reviewer for their comments. Below, we respond to each comment. Comments to the Author Reviewer #1: Summary In this study, authors used data from LiveWell observational cohort to identify the most important sociodemographic and behavioural factors related to the diet quality of low-income adults. Diet was assessed using 2x self-administered 24-h dietary recalls (ASA24) and the HEI-2020. Authors found that the most important factors associated with lower HEI-2020 were house ownership, male, tobacco use, marijuana use, and skipping meals. Strength of this study includes dietary assessment instrument and explicit/clear description of the HEI-2020 score calculation (ie, population ratio and simple scoring), comprehensive data collection and consideration of participants from hardly reached communities. I congratulate authors for their work. I only have minor comments. Minor The modelling approach and the underlying data are not adequate to confirm causal relationships, which is fine in the context of this descriptive study and adequately mentioned in limitations (L309). However, readers may be tempted to interpret findings as if acting on any factors would necessarily lead to health/diet improvements. I suggest authors further add a statement about this issue rather than only in limitations. In other words, I think it is relevant to remind readers how findings should be (correctly) interpreted early in the discussion. Response: We have added the following sentence to the beginning of the discussion section: “We caution that the associations between factors and diet quality cannot be interpreted causally; therefore, addressing any individual factor may not necessarily lead to direct improvement in diet quality.” L168. Please indicate how many bootstrap samples were used and the specific method (i.e., normal approximation or percentile bootstrap)? Response: We updated the description of bootstrap resampling in the analysis section as such: “Bootstrap resampling with 200 bootstraps was utilized to estimate 95% confidence intervals (CIs) using the percentile method as appropriate since the bootstrap distribution was approximately normal.” L187-190. Proportion of missing data: to be consistent with the STROBE reporting checklist item 14 (Vandenbroucke et al., 2007), please add a table that indicates the number of participants with missing data for each variable of interest. Response: We have added a supplemental table, Supplemental Table 1, that indicates the number of participants with missing data for factors included in the LASSO model. In the analysis section, when discussing imputation of missing data, we refer readers to this supplemental table. Interpretation (ie, L250). An HEI score of 63 is higher than mean scores typically reported in NHANES. For example, 56.6 was the mean score reported by (Reedy et al., 2018). I acknowledge there is room for improvement, but it does not seem entirely accurate to state that diet quality is not aligned with guidelines. Response: Instead of stating that the HEI score of 63 was “not aligned” with dietary guidelines, as the reviewer suggests, we have moderated the wording. Instead, we state that the HEI score “could be improved to better align with dietary guidelines.” We believe this statement is appropriate given that the score for our sample is below the score of 74 that would meet Healthy People 2020 goals (see citation 41: Wilson, 2016). We reference this citation in the paragraph that immediately follows the revised statement. Code sharing. I recommend authors make the analytic code available in supplemental material or in a code repository. Response: We would be happy to share analytical code. In the Data Availability Statement, we wish to indicate information about the access of the analytic code: “Analytical code used in this analysis to generate results can be accessed via Open Science Framework (DOI 10.17605/OSF.IO/WY4XF). Citation: Cheng J. Analytic Code: Sociodemographic and Behavioral Factors Associated with Diet Quality among Low-income Community Health Center Patients with Hypertension. doi:10.17605/OSF.IO/WY4XF.” https://doi.org/10.1371/journal.pone.0299781.r002
15 Aug 2024 Decision Letter - Jinyi Wu, Editor PONE-D-24-06116R1Sociodemographic and Behavioral Factors Associated with Diet Quality among Low-income Community Health Center Patients with HypertensionPLOS ONE Dear Dr. Cheng, 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 29 2024 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, Jinyi Wu, MD 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. 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) ******** 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: Partly ****** 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 ****** 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: I thank the authors for diligently addressing my previous comments. Thank you for this work. I have no additional feedback to provide. Reviewer #2: In this study, the authors used data from a low-income, urban cohort to identify correlates of diet quality among individuals with hypertension. Interventions to improve the health and well-being of underserved populations is important, however, I have some serious concerns about the paper in its present form. This seems like some of the exploratory analysis that would be necessary in informing intervention design, however, I do not think there is enough here for a standalone paper. I am not sure that it adds much to the literature beyond what is already known. I am also concerned about the discussion of certain factors as causal or as a point for intervention (e.g., smoking behavior). While smoking and diet are correlated, there is no causal relationship, and while the authors acknowledge this, they suggest using smoking behavior to inform their intervention anyways. This also has the potential to reinforce stigmas against those the intervention seeks to serve, and so I recommend that the authors consider reframing the discussion around their findings. Additional comments: The authors mention that NIH/AHA recommend CHW-led interventions (refs. 11,12). Are there any examples of successful CHW-led interventions to improve dietary quality among low-income populations? If so it may be helpful to reference these; if not it may be helpful to explicitly mention that this is a gap that the study team aims to fill. While I appreciate that this is a secondary data analysis, it seems like the best way to determine what sorts of interventions would work well for this population would be to ask the participants directly. I recommend some qualitative work to support the design of this intervention. It would also help contextualize some of the results reported here, such as meal skipping. The reason for meal skipping (income, time constraints, lack of access to appropriate food preparation facilities) is likely important for the participant’s overall diet quality and for the success of the intervention. If qualitative work is planned, I recommend mentioning this explicitly as something that will support the overall intervention design. Line 60 - A bit confusing why CHWs would seek to prioritize certain factors over the others – particularly for sociodemographic behaviors, but also for behavioral factors as these are correlates but not causal. I recommend cutting this paragraph. Line 79. Much of this data collection took place during the first months of the COVID pandemic. This was a time of unprecedented disruption to people’s lives, the food system, and the healthcare system. There were massive surges in food insecurity in the US during these months. I suggest the authors add a sentence in the limitations acknowledging the potential role of COVID on the data collection. Lines 95-96 Please clarify what is meant by “Gender, race, education, marital status, and employment categories were collapsed because of small cell sizes.” It would be helpful if there was a supplemental table that detailed what all categorical options were and how categories were collapsed. Lines 110-120 are their full lists of what is included in these scales? And are there citations for these measures? Many of the other variables included come from validated questionnaires with citations (e.g., General Anxiety Disorders Questionnaire). It would be helpful if the full response options were provided in a supplement, and if the validations of these measures were cited (where available). Lin 154. Why was HEI the metric of diet quality used and not (for example) DASH, which is mentioned in both the introduction and the discussion as a dietary pattern to address hypertension, or A-HEI, which has stronger associations with BP? I suggest the authors add a sentence justifying the use of HEI as the indicator of diet quality rather than one of these other metrics. The discussion could benefit from discussion of different interventions and policies beyond CHWs to improve diet and hypertension among this population. For example, we know that cash transfers are more impactful in improving diet and health, especially among low-income populations such as that included in this study. The authors mention time constraints as a barrier to healthy diet among low-income interventions. How would a CHW-led intervention help to address time constraints experienced by these individuals? Wouldn’t participation in such an intervention just be an additional time pressure? Figure 2 – this is a bit hard to read as constructed, I recommend adding additional spacing between the different factors to make it easier to read ****** 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. https://doi.org/10.1371/journal.pone.0299781.r003
Revision 2
16 Aug 2024 Author Response Response to Reviewers Reviewer #2: In this study, the authors used data from a low-income, urban cohort to identify correlates of diet quality among individuals with hypertension. Interventions to improve the health and well-being of underserved populations is important, however, I have some serious concerns about the paper in its present form. This seems like some of the exploratory analysis that would be necessary in informing intervention design, however, I do not think there is enough here for a standalone paper. I am not sure that it adds much to the literature beyond what is already known. I am also concerned about the discussion of certain factors as causal or as a point for intervention (e.g., smoking behavior). While smoking and diet are correlated, there is no causal relationship, and while the authors acknowledge this, they suggest using smoking behavior to inform their intervention anyways. This also has the potential to reinforce stigmas against those the intervention seeks to serve, and so I recommend that the authors consider reframing the discussion around their findings. Response: Thank you for this thoughtful suggestion. We have removed any sentences which may have indicated causal relationships between social factors (e.g., smoking) and dietary intake or reinforced stigma (e.g., we have cut the sentence: “Awareness of substance use patterns could help contextualize dietary guidance provided by a CHW and provide an opportunity for discussing the relationship of the substance, such as tobacco or alcohol use, with hypertension.”. Additional comments: The authors mention that NIH/AHA recommend CHW-led interventions (refs. 11,12). Are there any examples of successful CHW-led interventions to improve dietary quality among low-income populations? If so it may be helpful to reference these; if not it may be helpful to explicitly mention that this is a gap that the study team aims to fill. Response: This is a helpful suggestion. We note the similarities between our current and planned work as well as how our work expands on that which has already been done: “CHW-delivered hypertension programs are promising ways of reaching diverse participants in consultation with, and outside of, primary care (44, 45). Other CHW-led interventions with dietary components show potential effectiveness in reducing blood pressure and improving health behaviors although diet quality measures, such as the HEI, are not evaluated (46-48). As with other CHW-led hypertension interventions, our planned intervention development and evaluation will include qualitative work to complement our quantitative analyses (46, 49). Thus, we have planned semi-structured interviews with both patients and CHWs, in order to contextualize our current findings and to explore if and how to address these factors in our intervention design and delivery (e.g., involving female partners in the intervention). Thus, our work utilizes similar practices as other promising interventions and expands on existing literature as we will explicitly focus on robust measurement of diet quality outcomes. While I appreciate that this is a secondary data analysis, it seems like the best way to determine what sorts of interventions would work well for this population would be to ask the participants directly. I recommend some qualitative work to support the design of this intervention. It would also help contextualize some of the results reported here, such as meal skipping. The reason for meal skipping (income, time constraints, lack of access to appropriate food preparation facilities) is likely important for the participant’s overall diet quality and for the success of the intervention. If qualitative work is planned, I recommend mentioning this explicitly as something that will support the overall intervention design. Response: We completely agree with the reviewer’s comment, and we are in the process of conducting qualitative work to build on and complement this analysis. As recommended by the reviewer we add a sentence explicitly acknowledging the value of this qualitative work: “As with other CHW-led hypertension interventions, our quantitative analysis should be complemented by qualitative work. Thus, we have planned semi-structured interviews with both patients and CHWs, in order to contextualize our current findings and to explore if and how to address these factors in our intervention design and delivery (e.g., involving female partners in the intervention).” Line 60 - A bit confusing why CHWs would seek to prioritize certain factors over the others – particularly for sociodemographic behaviors, but also for behavioral factors as these are correlates but not causal. I recommend cutting this paragraph. Response: We have cut this paragraph as recommended. Line 79. Much of this data collection took place during the first months of the COVID pandemic. This was a time of unprecedented disruption to people’s lives, the food system, and the healthcare system. There were massive surges in food insecurity in the US during these months. I suggest the authors add a sentence in the limitations acknowledging the potential role of COVID on the data collection. Response: Thank you. We have added a sentence to this effect: “Finally, this was a relatively small sample of patients from one urban health system in the northeast US and data collection occurred during the COVID-19 pandemic. Thus, results may not be generalizable to patients from rural areas or from other regions within the US or outside the US, and the pandemic might have temporarily increased the reporting of social needs and/or lead to the worsening of diet quality.” Lines 95-96 Please clarify what is meant by “Gender, race, education, marital status, and employment categories were collapsed because of small cell sizes.” It would be helpful if there was a supplemental table that detailed what all categorical options were and how categories were collapsed. Response: We have provided analytical code (and formats) on open science framework (DOI 10.17605/OSF.IO/WY4XF) which includes information on the categories before and after collapsing. Lines 110-120 are their full lists of what is included in these scales? And are there citations for these measures? Many of the other variables included come from validated questionnaires with citations (e.g., General Anxiety Disorders Questionnaire). It would be helpful if the full response options were provided in a supplement, and if the validations of these measures were cited (where available). Response: For the 3-item housing related questions we have added two citations about the development and validation. The other items in this paragraph were created to be relevant to our population and resources. These items on living site problems, receiving housing assistance, receiving transportation assistance, and help obtaining these types of assistance have been added to a supplement. We direct readers in this paragraph to view the supplement. We also note that our analytical code which is available on open science framework (DOI 10.17605/OSF.IO/WY4XF) does provide descriptions of each of these items (i.e., a variable label) as well as for all items included in the analysis. We hope that this is sufficient detail for the understanding of readers. Lin 154. Why was HEI the metric of diet quality used and not (for example) DASH, which is mentioned in both the introduction and the discussion as a dietary pattern to address hypertension, or A-HEI, which has stronger associations with BP? I suggest the authors add a sentence justifying the use of HEI as the indicator of diet quality rather than one of these other metrics. Response: Thank you. We have added a sentence indicating that the HEI was used as it aligns with the US Dietary Guidelines for Americans. While preferences may differ on which index to use, we find it useful in our work to align with the guidelines as they are familiar to a broad segment of both the research community and the general population: “We chose to use the Healthy Eating Index-2020 (HEI-2020) (28, 29) as the measure of diet quality in this study as it is a valid and reliable measure of overall diet quality aligned with the Dietary Guidelines for Americans.” We have also added a sentence showing that the HEI does relate to blood pressure and is correlated with other indices, specifically DASH and AHEI: “The HEI has been shown to relate to blood pressure, (30, 31) correlate with other diet quality indices, and shows a similar relationship to CVD mortality as other indices (32).” The discussion could benefit from discussion of different interventions and policies beyond CHWs to improve diet and hypertension among this population. For example, we know that cash transfers are more impactful in improving diet and health, especially among low-income populations such as that included in this study. Response: As the reviewer indicates, the purpose of this analysis was to inform a CHW healthy eating intervention as it is being developed through both quantitative and qualitative means. We believe that additional discussion of the effectiveness of non-CHW nutrition education forms of intervention such as cash transfer programs is beyond the scope of this paper. However, we do agree with the reviewer that cash transfers are a very promising form of intervention for low socioeconomic groups that should be further researched and promoted. To address the role of financial support or incentives as a potential strategy to improve diet, we have added to our discussion: “…connecting patients with community-based nutrition services may help improve the diet of individuals with hypertension as our model suggested that receiving support for food acquisition (i.e., meals at a community organization and receiving a supermarket gift card) was positively associated with diet quality in this mostly low-income population.” The authors mention time constraints as a barrier to healthy diet among low-income interventions. How would a CHW-led intervention help to address time constraints experienced by these individuals? Wouldn’t participation in such an intervention just be an additional time pressure? Response: Thank you for this comment. Although participating in the CHW program requires time, the goal is to make the intervention as convenient and efficient as possible for the participant. For example, the CHW will provide guidance by phone or video call at a time and place that works for the participant, and therefore this does not require time spent traveling to the clinic for a visit with a dietitian or other clinician. In addition, our goal is that through participating in the CHW program, participants can learn how to address other time constraints specific to shopping and food preparation and that they can use these skills during and after the program has ended. We have added the sentence: “For example…meal planning, and quick healthy go-to meals. We note that while participation in a phone- and web-based CHW -led program is a temporary time constraint while enrolled, we hope that CHWs can help patients develop and/or strengthen skills that reduce the time burden associated with shopping and cooking.” Figure 2 – this is a bit hard to read as constructed, I recommend adding additional spacing between the different factors to make it easier to read Response: Thank you for this suggestion. We have increased spacing. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0299781.r004
6 Sep 2024 Decision Letter - Jinyi Wu, Editor Sociodemographic and Behavioral Factors Associated with Diet Quality among Low-income Community Health Center Patients with Hypertension PONE-D-24-06116R2 Dear Dr. Cheng, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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, Jinyi Wu, MD 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 #3: 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 #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: 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 #1: Yes Reviewer #3: 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 #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: (No Response) Reviewer #3: (No Response) ****** 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 ******** https://doi.org/10.1371/journal.pone.0299781.r005
Formally Accepted
10 Sep 2024 Acceptance Letter - Jinyi Wu, Editor PONE-D-24-06116R2 PLOS ONE Dear Dr. Cheng, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Jinyi Wu Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0299781.r006

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