PONE-D-24-03952Prevalence and risk factors for type-2 diabetes, hypertension, and metabolic syndrome among adults living in marginalized rural communities in tropical coastal EcuadorPLOS ONE

Dear Dr. Cooper,

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.

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PLOS ONE

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"Universidad Internacional del Ecuador (grant EDM-INV-04-19)"

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Additional Editor Comments:

​Monsermin Gualan et al. conducted a cross-sectional study to evaluate the prevalence of diabetes, hypertension, and metabolic syndrome (MS) in a marginalized rural zone in the tropical coastal area of Ecuador. The authors sampled 931 individuals using diverse questionnaires and collected anthropometrical and biochemical samples. They described a high prevalence of diabetes, hypertension, and MS (affecting over half of the sample) and evaluated associated factors. They found an association between adiposity metrics, non-agricultural work, and these health outcomes. This study offers significant public health insights for Ecuador, but several aspects require clarification.

Abstract

• Recommend changing “higher values” to “higher prevalence” for clarity.

• Suggest removing the mention of previous CVD prevalence, as it is unrelated to the study's objectives.

Introduction

• The introduction is well-written. I would suggest that strengthening the justification for this study would enhance its impact. Specifically, elucidate how the study's findings can benefit indigenous and vulnerable populations whose characteristics have been diminishing.

Methods

• Clarify whether fasting glucose levels >126 mg/dl were considered in the T2D diagnosis.

• Justify the choice of >190 mg/dl as the threshold for elevated cholesterol, differing from the AHA guideline of ≥200 mg/dl.

• Recommend splitting the “definitions” paragraph into two: one for “outcome definitions” (T2D, arterial hypertension, and MS) and another for defining other conditions, such as adiposity indicators.

• When estimating the age and sex-adjusted effects of variables on outcomes, clarify if “effects” refers to adjusted prevalences.

Results

• For Figure 2, include the 95% confidence intervals (CI) for each outcome, possibly adjusting for age and sex via log binomial regression to more accurately model outcome probabilities. Reference: https://www.bookdown.org/rwnahhas/RMPH/blr-log-binomial.html

• In the “Population-weighted prevalence of diabetes, hypertension, metabolic…“paragraph, the authors first describe the prevalence of T2D, then HTN, and lastly, MS, but in Figure 2, these are displayed in reverse order. I would suggest arranging them into a sequence described in the results section.

• Clarify whether the associations in Table 3 derive from a saturated model or represent bivariate adjustments.

• Consider relocating Table 5 to the Supplementary Material.

Discussion

• An excellent discussion.

Figures and Tables

• In Figure 1, it would be optimal to include a scale for each transition in territory.

• In Figure 2, please change the scale of the y-axis to be interpreted on a 100% scale instead of a proportion.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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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

Reviewer #3: 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: Dear Authors,

-My main question is "not clear the novelty of the study". Considering numerous published studies from Ecuador, and NCD data of 2020 (Ref.11), data of this sub-national study is interesting for local Journals, and their results cannot generalize to the country population.

-What is your mention of this sentence "evaluation of participants between 6 and 10 am"?

-Please clarify method/measurement of visceral adiposity index, body fat, HOMA-index, and LDL in the method.

-For prediction, did you just adjust with age and sex? Where are ROC cure, sensitivity and specificity?

Minor revisions:

-Nearly 30% of the Ref. are published in more than 10 years ago. Please update.

-Tables S1, and S2 can be removed.

Best Regards,

Reviewer #2: Gualan et al performed a cross-sectional study looking at the prevalence of cardiometabolic disease and risk factors in an Ecuadorian rural population. Authors concluded there was an unexpectedly high prevalence of diabetes, hypertension and metabolic syndrome.

The manuscript is mostly well written. There’s certainly a gap in the care of rural communities and the need to understand more what their risk factors are.

The novelty of this manuscript is the population that was studied.

Comments and suggestions:

1. Line 147 “sex, sex and age” needs to be fixed

2. As part of the questionnaire, was “regular exercise” asked about?

3. Smoking is a known risk factor for the development of hypertension and diabetes, can you include reasons why your think there wasn’t an association in this cohort?

4. 20.4% prevalence of T2DM is very high, even compared to other studies done in rural communities in Ecuador. I will recommend elucidating more in the discussion why the authors think that is the case. Maybe the criteria used to define diabetes by using “clinical history of diabetes treatment” was a bit inaccurate as it may also be including people with prediabetes. We know some patients when they have prediabetes may be started on metformin for example. It will be relevant to include the percentage of patients with an “objective” diagnosis of diabetes based on HbA1c of 6.5% or greater.

5. There’s a study looking at the prevalence of diabetes in other rural areas in Ecuador published in July of 2023

Puig-García M, Caicedo-Montaño C, Márquez-Figueroa M, Chilet-Rosell E, Montalvo-Villacis G, Benazizi-Dahbi I, Peralta A, Torres-Castillo AL, Parker LA. Prevalence and gender disparities of type 2 diabetes mellitus and obesity in Esmeraldas, Ecuador: a population-based survey in a hard-to-reach setting. Int J Equity Health. 2023 Jul 1;22(1):124. doi: 10.1186/s12939-023-01939-x

It will be worth mentioning it in the discussion – compare/contrast. This study also found higher prevalence of diabetes in women but the overall prevalence of diabetes was lower than the one described in this study.

6. HbA1c should also be shown as categorial variable, A1c >= 6.5% and <6.5%

Reviewer #3: I have had the opportunity to review the manuscript titled " Prevalence and risk factors for type-2 diabetes, hypertension, and metabolic syndrome among adults living in marginalized rural communities in tropical coastal Ecuador ", which presents a cross-sectional study aimed at reporting the prevalence of cardiovascular diseases such as diabetes, metabolic syndrome, and hypertension in rural communities of a coastal province in Ecuador, characterised by the socio-cultural traits of the Montubio population in the area. The researchers unveil concerning prevalence rates for all these conditions, particularly for metabolic syndrome, and surprisingly high rates of diabetes compared to national surveys and other territories.

I believe this work addresses a fundamental issue from a quite insightful perspective, taking into consideration the obesogenic context in which individuals live, subjected to structural inequalities in access to resources and healthcare, subsequently impacting health inequities. The authors do a great work exposing these determinants in the discussion of the paper. Therefore, in my opinion, this study would be suitable for publication in PLOS ONE, as it provides essential information for the development of public policies addressing these issues in hard-to-reach communities in low- and middle-income countries such as Ecuador.

However, I think it is important to make a series of minor changes before its publication, which I have listed below.

Line 90 � Communities were selected by convenience sampling. Censuses for each community were drawn up by community representatives: How was this contact to the community done? Was there a previous relationship between the authors and the population? Were the censuses updated for the study? Consider providing further information regarding the sample, the community representatives and the extend of their role in the study.

Line 100 � Data collection: Following the previous point, who took part in the collection of data? Did it involve local health promotors or just the study team?

Line 120 � Definitions: a) Consider including the categorisation of the risk factors such as occupation and ethnicity (do “not mestizos” include white and indigenous in the same category?). It would facilitate the reading of the manuscript, because it is only mentioned afterwards in the results. b) Line 136-137: cardiovascular disease is shown in tables disaggregated as diabetes, hypertension and hypercholesterolemia, maybe you should indicate it in this section to clarify the understanding of the tables (you show e.g. hypertension as the measurement + history, and then only as history.

Lines 147-148 � “stratified by sex, sex and age (…) and their interaction where (when would be more correct) statistically significant”.

Line 161 � Of 1,525 adults eligible according to the house-to-house census, 1,010 adults were recruited from 10 communities, and 931 (61.0% of those eligible) had complete(d) data (collection) and were included in the analysis.

Line 167 � alcohol and tobacco have important differences in consumption between men and women, consider to desegregate.

Line 169 � were any of those adiposity indicators different enough between men and women to consider mention a couple of them in the text?

Lines 189-191� Prevalence of HTN increased with age, although there was some evidence of an interaction with sex, with a particularly steep increase in prevalence in women (consider to reformulate to increase clearness: particularly showing a steep increase…)

Lines 193-196 � Some commas are missing: Prevalence of MetS was similar in both sexes up to about 40 years, after which prevalence was greater in women. An analysis of 576 participants, for whom blood pressure could be repeated at home, showed a lower average systolic blood pressure in the home setting.

Line 211� I am not sure why you only mention some of the risk exposures that show a significant p-value, for example for DM2: hypertension (history, consider using HTN in the table next to the hypertension in chronic diseases), lives with a partner, obesity, triglycerides and insulin resistance are also significant. If you only mention some relevant, please indicate in the text.

Line 258 � Table 5 (keep using the same p value, sometime .001 /0.001 // age (-0.004 (-0.007 - 0.0??)) // try to keep the minus next to the number -0.451 (-0.589 - -

0.313)

Line 393 � Adjusted for/by?? for seems to be a mistake

Lines 400-403 � “20 years or so” does not look like a good fit for an academic text. consider the following idea to improve the academic writing: “Environmental degradation and accelerated urbanization occurring in these transitional communities over a period of approximately 20 years, with increased out-migration, occupational shifts, and changes in diet and physical activity are likely to be important causes of cardiovascular diseases.”

Lines 403-407 � Rephrase the last paragraph as it is not completely clear and suggests that the data show a preventable morbidity that could be effectively targeted. // more modern ways of living (lyfestyles?) // mitigated through (by) targeted public health strategies

While the discussion is well organised and rich, helping to understand the problem of this hard-to-reach areas with great detail and sense of understanding, the conclusion needs some improvement, as mentioned before. I appreciate the opportunity to review this manuscript, congrats for your work.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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PONE-D-24-03952R1Prevalence and risk factors for type-2 diabetes, hypertension, and metabolic syndrome among adults living in marginalized rural communities in tropical coastal EcuadorPLOS ONE

Dear Dr. Cooper,

Thank you for submitting your manuscript to PLOS ONE. The manuscript could be accepted for publication after addressing minor comments made by one revisor. 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 Jul 31 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,

Neftali Eduardo Antonio-Villa, MD PhD

Academic Editor

PLOS ONE

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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:

Dear authors,

Thank you for addressing the comments made by all reviewers.

One reviewer made additional valuable comments that must be addressed before making a final decision.

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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: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: 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 #2: 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: (No Response)

Reviewer #2: 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: Dear Authors,

The quality of manuscript is significantly improved.

Please consider following minor revisions:

-Consider language editing in whole manuscript

-Brief title and change it to an interesting tile such as:

Cardiometabolic diseases and their associated risk factors in transitional rural communities of Ecuador

-Expand words in the first use, for example STEPs

-Correct 'sera" in line 121.

-Insert unit of all variables in the tables.

-Merge table 4 and 1.

-Fig S1, not necessary. Plz omit.

-Recheck number of table S3, it is table 5 or S3?

Best Regards,

Reviewer #2: (No Response)

Reviewer #3: All comments have been adequately addressed following suggestions and corrected minor revisions. The data analyzed in the study are provided in the supporting information. Congratulations on your work.

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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.

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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

Reviewer #3: No

**********

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Cardiometabolic diseases and associated risk factors in transitional rural communities in tropical coastal Ecuador

PONE-D-24-03952R2

Dear Dr. Cooper,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Neftali Eduardo Antonio-Villa, MD PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear authors,

All minor comments were appropriately addressed, and an extensive English edition was produced. I can now process and recommend the acceptance of the manuscript in its current form. It has been a true honor to review and manage this manuscript. It will contribute to understanding prevalent cardiometabolic risk factors in Ecuador.

Reviewers' comments: