Associations of psychosocial factors and cardiovascular health measured by Life’s Essential 8: The Atherosclerosis Risk in Communities (ARIC) study

Kennedy M. Peter-Marske; Anna Kucharska-Newton; Eugenia Wong; Yejin Mok; Priya Palta; Pamela L. Lutsey; Wayne Rosamond

doi:10.1371/journal.pone.0305709

Peer Review History

Original SubmissionSeptember 4, 2023
1 Apr 2024 Decision Letter - Mohammad Reza Mahmoodi, Editor PONE-D-23-24863Associations of psychosocial factors and cardiovascular health measured by Life’s Essential 8: the Atherosclerosis Risk in Communities (ARIC) StudyPLOS ONE Dear Dr. Peter-Marske, 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 May 16 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. 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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 ******** 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: Abstract In the methods section, it would be useful to mention the study setting. Indicate whether primary or secondary data source was used. Also, would be useful to mention the categories of scores used in the analysis. Background Some grammatical errors that need proof-reading. E.g., No full stop on line 80, In line 88 full stop should come after the citation and this should be revised throughout the background and other parts of the manuscript. Sentence in line 81 that ends with ‘CVD events’ needs to be supported by a reference. In line 104 CV is not expanded anywhere in preceding text. Please expand the abbreviation. Methods Please add some brief information on the sampling strategy for the ARIC study. In the covariate section, please provide further details how visit 1 variables were used to derive visit 2 estimates i.e. for age. For the race-center variable, please provide some context why MN and MD don’t have black and MS doesn’t have white. Did you consider using ordinal logistic regression as the levels of cardiovascular health seem to be ordinal in nature? If so, why wasn’t ordinal considered. It would be good to have this as a sensitivity analysis to support the linear regression results. The figures seems to be a bit blur. Please provide a clearer version. Results For table 2 it would be useful to provide some indications of statistical differences from hypothesis tests e.g. chi-squared for categorical variables and t-test/ANOVA for continuous. You can use * to indicate significance against the variables and add as notes below the table. Reviewer #2: Tile: OK Abstract: I think it is essential to show the descriptive measures of Life’s Essential 8 scores in each group of psychosocial factor assessments. In this case, it is essential to show the classification of these scores in more detail in material and method part of this section. It seems the stated conclusion is not supported by the evidences already provided in the result part. Keywords: OK Introduction: OK Material and method: please notice to the following issues in this section: - Please show how ethical issues have been dealt with and who has approved these issues in the context of the paper. - For a better understanding of the setting of the study, please define the inclusion and exclusion criteria of the recruited participants in more detail, I think referring to the paper of the original study is not enough for such a comprehensive paper. - Since this is a cross sectional study, I think it is necessary to define the sampling method as well as the method of sample weighting (if necessary) in more detail. - Please show the reliability measure of the questionnaire proposed for social isolation (line 138). This is true for the anger and depressive symptoms questionnaires as well (lines 150-158). - Please define how the proposed variable of the study have been measured (in terms of time the method of invitation of the participants in to the study). - I think it is essential to define how covariates were selected to be entered to the multivariate regression model. Results: considering the following comments is appreciated in this section: - Please show the P values of the comparisons of different variable in table 2. It also not necessary to express the findings already shown in the table once again in the context of the paper. Generally speaking, showing the univariate comparing analysis in the LE8 groups is mandatory before multivariate analysis. - Please complete the legend of different figures (e.g., the colors of figure 1). Discussion: OK References: If possible, please use more recent references. ******** 6. 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Revision 1
6 May 2024 Author Response Reviewer #1: Abstract 1. In the methods section, it would be useful to mention the study setting. Indicate whether primary or secondary data source was used. Also, would be useful to mention the categories of scores used in the analysis. Thank you for this comment. We have added the following to the abstract: “...in this secondary data analysis using cross-sectional data from the ARIC cohort study.” The categories of LE8 scores were not used in multivariable analyses, so to clarify we have specified that we assessed continuous LE8 in the abstract methods section. We additionally added the categories of the psychosocial exposures (high, moderate, and low) to the methods section. 2. Background Some grammatical errors that need proof-reading. E.g., No full stop on line 80, The sentence referenced here ends at line 81, after listing a variety of cardiovascular-related diseases and their complications and progression. 3. In line 88 full stop should come after the citation and this should be revised throughout the background and other parts of the manuscript. Thank you. This has been revised throughout the paper. 4. Sentence in line 81 that ends with ‘CVD events’ needs to be supported by a reference. We thank the reviewer for this comment. References have been added for this sentence. 5. In line 104 CV is not expanded anywhere in preceding text. Please expand the abbreviation. This has been fixed, thank you for noticing this error. 6. Methods Please add some brief information on the sampling strategy for the ARIC study. The ARIC study employed various sampling methods, of which have been previously described. It would take many sentences to fully describe this sampling, therefore we added a reference and statement to the methods reflecting this: “...using various probability sampling methods described in detail elsewhere(19).” 7. In the covariate section, please provide further details how visit 1 variables were used to derive visit 2 estimates i.e. for age. The following text has been added: “by adding the time between visits to the participant’s age at Visit 1, rounding down to a whole number.” 8. For the race-center variable, please provide some context why MN and MD don’t have black and MS doesn’t have white. This is due to the sampling strategy of the original ARIC cohort. The following text has been revised to reflect this and give a bit more context: “Due to the sampling strategies, race and study-center are highly correlated in the ARIC cohort. Therefore, the variable race-center was developed as a 5-level categorical classification of race and field center (MN/White, MD/White, NC/White, NC/Black, MS/Black).” 9. Did you consider using ordinal logistic regression as the levels of cardiovascular health seem to be ordinal in nature? If so, why wasn’t ordinal considered. It would be good to have this as a sensitivity analysis to support the linear regression results. We ran all models as logistic regressions estimating the odds of having high LE8 scores compared to the odds of having moderate/low LE8, as has been commonly done when assessing LS7 scores. Associations were in the same direction as linear regression results. We have chosen not to include these models because one of the major benefits of the LE8 score compared to the LS7 is the granularity of the measure and its ability to give individuals more “credit” for intermediate measures of cardiovascular health on a scale of 0 to 100 rather than categorizing them simply into three bins. However, to the reviewer’s recommendation, we have added this as a sensitivity analysis in the methods and results section in case readers wonder about this. “As a further sensitivity analyses, we assessed the same associations of psychosocial factors with the odds of having a high LE8 score compared to moderate/low LE8 score using adjusted logistic regressions.” “When assessing the odds of high LE8 scores, the presence and direction of associations agreed with analyses of LE8 modeled continuously.” 10. The figures seems to be a bit blur. Please provide a clearer version. We thank the reviewer for this comment. We also noticed that the figures became blurry when converted to the pdf to send to reviewers, but they were not burry in the versions that we submitted to the journal. We will work with the journal to ensure that the final copy of figures published is clear and easy to read. 11. Results For table 2 it would be useful to provide some indications of statistical differences from hypothesis tests e.g. chi-squared for categorical variables and t-test/ANOVA for continuous. You can use * to indicate significance against the variables and add as notes below the table. We thank the reviewer for this suggestion. We did not perform statistical tests for the variables listed in the descriptive Table 2 since these are descriptive statistics of the sample characteristics, and not presented for hypothesis testing. This method is suggested here: “Inferential measures such as standard errors and confidence intervals should not be used to describe the variability of characteristics, and significance tests should be avoided in descriptive tables.” - https://www.acpjournals.org/doi/10.7326/0003-4819-147-8-200710160-00010-w1 12. Reviewer #2: Tile: OK Abstract: I think it is essential to show the descriptive measures of Life’s Essential 8 scores in each group of psychosocial factor assessments. In this case, it is essential to show the classification of these scores in more detail in material and method part of this section. It seems the stated conclusion is not supported by the evidences already provided in the result part. Due to word count limits (300 words total, currently at 293), we are not able to elaborate extensively on how psychosocial factors were assessed in the abstract. We have clarified that these measures were assessed categorically, and the scale direction of the LE8 score. “Life’s Essential 8 was scored per the American Heart Association definition (0-100 range); higher scores indicate better cardiovascular health.” “Associations of categories (high, moderate, and low) of each psychosocial factor” We also changed the directionality of the language in the conclusion to better match that of the results section: “Less favorable measures of psychosocial health were associated with lower Life’s Essential 8 scores compared better measures of psychosocial health among middle-aged males and females.” 13. Keywords: OK Introduction: OK Material and method: please notice to the following issues in this section: - Please show how ethical issues have been dealt with and who has approved these issues in the context of the paper. Please see the following text in the methods section: “Protocols for all in-person visits were approved by the institutional review boards at the University of North Carolina at Chapel Hill, Wake Forest University, University of Mississippi Medical Center, University of Minnesota, and Johns Hopkins University. All participants provided written informed consent.” 14. For a better understanding of the setting of the study, please define the inclusion and exclusion criteria of the recruited participants in more detail, I think referring to the paper of the original study is not enough for such a comprehensive paper. The inclusion/exclusion criteria for the ARIC study are as follows and is as described in this manuscript: “men and women ages 45-64 years were recruited from four communities in the United States (Forsyth County, NC; Jackson, MS; suburbs of Minneapolis, MN; and Washington County, MD)”. There were no other major inclusion or exclusion criteria from the general ARIC cohort, please see the new reference 19 for confirmation of this. From this original cohort, we applied many exclusion criteria which are outlined in the second paragraph of the methods section. 15. Since this is a cross sectional study, I think it is necessary to define the sampling method as well as the method of sample weighting (if necessary) in more detail. Sample weighting was not applicable to this study as this was a community-based cohort. The sampling methods for each study site differed slightly. Detailing the sampling method would involve much description of which has already been published; therefore reference 19 and the following sentence have been added: “Briefly, from 1987-1989, 15,792 men and women ages 45-64 years were recruited from four communities in the United States (Forsyth County, NC; Jackson, MS; suburbs of Minneapolis, MN; and Washington County, MD) using various probability sampling methods described in detail elsewhere(19).” 16. Please show the reliability measure of the questionnaire proposed for social isolation (line 138). This is true for the anger and depressive symptoms questionnaires as well (lines 150-158). The reliability of social isolation and trait anger have been previously published for different versions of these tools (using a different number of questions from the measures), therefore we did not report the reliability. Additionally, the internal consistency reported here for social support was for the 40-item measure, not the 16-item measure that is used in the present study, so this sentence has been revised to be more general: “This questionnaire has good internal consistency, and is highly correlated with other measures of social support(24, 25).” Depressive symptoms were derived using all but 3 questions from the Maastricht Vital Exhaustion questionnaire and therefore these 18 questions have not been validated as a measure of depressive symptoms. This was done so that we could incorporate the sleep-related items as a sleep measure in the LE8 score, and so that this measure would not be highly correlated with depressive symptoms since they are incorporated in the measure itself. 17. Please define how the proposed variable of the study have been measured (in terms of time the method of invitation of the participants in to the study). Please see the following text outlining when participants were recruited and completed Visit 1: “The baseline study visit (Visit 1, 1987-1989) was followed by additional in-person evaluations, along with yearly follow-up telephone calls and semi-annual follow-up calls starting in 2012.” The following text outlines how the psychosocial measures were administered and when: “The four psychosocial factors were measured using self-administered questionnaires at ARIC Visit 2 (1990-1992).” For components of LE8 timing of measurement, please see the following sentence and Table 1 for details on their measurement: “All LE8 components were measured at Visit 2, except diet and physical activity, which were measured at Visit 1 and are used as an approximation of these measures at Visit 2.” 18. I think it is essential to define how covariates were selected to be entered to the multivariate regression model. Thank you for this suggestion. The following sentence has been included in the methods section: “These covariates were identified a priori using substantive knowledge and prior literature.” 19. Results: considering the following comments is appreciated in this section: - Please show the P values of the comparisons of different variable in table 2. It also not necessary to express the findings already shown in the table once again in the context of the paper. Generally speaking, showing the univariate comparing analysis in the LE8 groups is mandatory before multivariate analysis. We thank the reviewer for this suggestion. We did not perform statistical tests for the variables listed in the descriptive Table 2 since these are descriptive statistics of the sample characteristics, and not presented for hypothesis testing. This method is suggested here: “Inferential measures such as standard errors and confidence intervals should not be used to describe the variability of characteristics, and significance tests should be avoided in descriptive tables.” - https://www.acpjournals.org/doi/10.7326/0003-4819-147-8-200710160-00010-w1 20. Please complete the legend of different figures (e.g., the colors of figure 1). Text for the figure legends includes the colors for figure 1: “Fig 1. Prevalence of Cardiovascular Health (low/red, moderate/yellow, and high/green) by high/isolated, moderate, and low levels of psychosocial factors; N=11,311” The following text has been added to clarify the figure legend for figure 2: “Fig 2. Cross-sectional adjusted associations of psychosocial factors with Life’s Essential 8 using multivariable linear regressions, estimates represented as squares with 95% confidence interval bars; N=11,311” 21. Discussion: OK References: If possible, please use more recent references. Thank you for this comment. We have included Wulandari and Li as two more recent references of psychosocial factors and cardiovascular disease. Attachments Attachment Submitted filename: LE8 PLOS One Reviewer Comments.docx https://doi.org/10.1371/journal.pone.0305709.r002
5 Jun 2024 Decision Letter - Mohammad Reza Mahmoodi, Editor Associations of psychosocial factors and cardiovascular health measured by Life’s Essential 8: the Atherosclerosis Risk in Communities (ARIC) Study PONE-D-23-24863R1 Dear Dr. Peter-Marske, 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, Mohammad Reza Mahmoodi, 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 #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? 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 #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 #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 #2: I think all of the comments are addressed by the distinguished authors and the paper can be accepted. ****** 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 #2: Yes: Babak Eshrati ******** https://doi.org/10.1371/journal.pone.0305709.r003
Formally Accepted
24 Jun 2024 Acceptance Letter - Mohammad Reza Mahmoodi, Editor PONE-D-23-24863R1 PLOS ONE Dear Dr. Peter-Marske, 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. Mohammad Reza Mahmoodi Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0305709.r004

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