Sex differences in the prevalence of metabolic syndrome and associated factors in the general population of Mongolia: A nationwide study

Lkham-Erdene Byambadoo; Narantuya Davaakhuu; Unursaikhan Surenjav; Bolormaa Norov; Enkhjargal Tserennadmid; Souphalak Inthaphatha; Kimihiro Nishino; Eiko Yamamoto

doi:10.1371/journal.pone.0311320

Peer Review History

Original SubmissionNovember 18, 2023
1 Feb 2024 Decision Letter - Jianhong Zhou, Editor PONE-D-23-37323Sex differences in the prevalence and factors associated with metabolic syndrome in the general population of Mongolia: A cross-sectional studyPLOS ONE Dear Dr. Yamamoto, 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 Mar 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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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. Note from Emily Chenette, Editor in Chief of PLOS ONE, and Iain Hrynaszkiewicz, Director of Open Research Solutions at PLOS: Did you know that depositing data in a repository is associated with up to a 25% citation advantage (https://doi.org/10.1371/journal.pone.0230416)? If you’ve not already done so, consider depositing your raw data in a repository to ensure your work is read, appreciated and cited by the largest possible audience. You’ll also earn an Accessible Data icon on your published paper if you deposit your data in any participating repository (https://plos.org/open-science/open-data/#accessible-data). 3. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. 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 ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: 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 Reviewer #2: 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 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: Dear Authors, Although the manuscript is well-written, there are some suggestions to improve its quality. -Title; It's better to mention STEPS or "a nation-wide study" instead of "a cross-sectional study" -Abstract, and methods of main manuscript: I suggest exclude data of individuals <18 years old. They categorized as adolescents. So, interpretation of the findings in them can be different from other age groups. If you prefer to remain their data, I think it's better to analysis their data separately from other age-groups. -Introduction; please update Ref.7. -Insert date of the study in line 69. -Method; please insert Ethical Committee approval code. -Results; It is missed expansion of some abbreviated words in the first use, such as HEC. -Please insert data of "central obesity" in all Tables. -For all tables, insert Statistical analysis test in the legend. -Please merge tables 3, and 4. -Insert additional Tables, based on "urban/rural", "BMI", and "central obesity", separately. -Discussion; The first paragraph should address the main findings. So, description of results and comparison with other studies should start from the second paragraph. -Ref.; nearly half of the Ref. are published on more than 10 years ago. Please update. -Consider language editing for whole manuscript. In some sentences is observed numerous grammatical errors. Best Regards, Reviewer #2: The authors have studied Sex differences in the prevalence and factors associated with metabolic syndrome in the general population of Mongolia in a cross-sectional study. It is a well-designed research in a large sample size that included a wide range of demographic and lifestyle factors in their analysis, which allowed for a more nuanced understanding of the factors that contribute to the development of metabolic syndrome in both men and women. Although similar research has been done and published, with its increasing prevalence, any additional information that sheds light on this condition is valuable. There are a few comments that need to be considered: Criteria used for MetS are described based on (IDF) and Adult Treatment Panel (ATP) for estimating the prevalence of MetS, but in other parts only IDF criteria are used. I think ATP criteria may not be necessary. The paper just can only use IDF critera. Table 2 provides no more information compared to Table 3. It could be potentially removed. Table 3, is the adjusted p-value calculated after adjustment with all variables ?(more than 15 variables are introduced) ****** 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 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.0311320.r001
Revision 1
1 Mar 2024 Author Response We would like to thank the editor and reviewers for reviewing our manuscript. We have revised the manuscript according to your comments, which were very helpful. The revised manuscript has been proofread by a native English speaker. The revisions have been completed and our responses are as follows. Journal 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 We have carefully revised our manuscript to meet PLOS ONE’s style requirements including the file names. 2. Note from Emily Chenette, Editor in Chief of PLOS ONE, and Iain Hrynaszkiewicz, Director of Open Research Solutions at PLOS: Did you know that depositing data in a repository is associated with up to a 25% citation advantage (https://doi.org/10.1371/journal.pone.0230416)? If you’ve not already done so, consider depositing your raw data in a repository to ensure your work is read, appreciated and cited by the largest possible audience. You’ll also earn an Accessible Data icon on your published paper if you deposit your data in any participating repository (https://plos.org/open-science/open-data/#accessible-data). Thank you for your suggestion. The data that support the findings of this study are available at the WHO NCD Microdata Repository (https://extranet.who.int/ncdsmicrodata/index.php/catalog). 3. 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. We have revised the references according to the comment No. 12 by Reviewer 1. The below table shows how we have revised references and reference numbers. We used EndNote (a software for reference manager) and revision of references and reference numbers cannot be retracted using the function of Track Change. Therefore, we have used red color for revised reference number and revised references in the reference section. We are very sorry that the reference style did not follow the journal style. We have checked the reference style on the journal site and revised the reference style in the manuscript. Ref. Original→　Revision 1 Deepa M, 2007 →The IDF consensus worldwide definition, 2006 5 Ford ES, 2005 →Yakoob MY, 2016 7 The IDF consensus worldwide definition, 2006 →Ref. number changed to 1. Ref. 8-21 →Ref. 7-20 22 NCEP expert panel on detection, evaluation,… , 2002 →Ref. number changed to 26 23 National Center for Public Health, 2020 →Ref. number changed to 21 24 Schneider JT, 2006 →(Ref. 22) Iwasa T, 2023. 25 Regitz-Zagrosek C, 2007 →(Ref. 23) Meloni A, 2023 26 Cornier MA, 2008 →(Ref. 24) Kautzky-Willer A, 2023 27 Kuk JL, 2010 →(Ref. 25) Tramunt B, 2020 28 Morales DD, 2008 →Changed to appropriate reference (Ref. 18) 29 Zago Z, 2004 →(Ref. 27) Li H, 2021 Ref. 30-36　→ Ref. 28-34 37 Fujita N, 2011 →(Ref. 35) Hirakawa M, 2015 38 Alkerwi A, 2009 →Erased due to Ref. 34 and Ref. 35 are enough for the sentence. 39 Yoon YS, 2004 →Erased due to Ref. 34 and Ref. 35 are enough for the sentence. Ref. 40-43→ Ref. 36-39 44 Halton TL, 2006 →(Ref. 40) Muraki I, 2016 45 Mozaffarian D, 2011 →(Ref. 41) Hojati A, 2024 46 Beulens JW, 2007 →(Ref. 42) Fung TT, 2016 Reviewer #1: 1. Title; It's better to mention STEPS or "a nation-wide study" instead of "a cross-sectional study." According to the reviewer’s comment and advice of the English proofreader, we have revised the title from “Sex differences in the prevalence and factors associated with metabolic syndrome in the general population of Mongolia: A cross-sectional study” to “Sex differences in the prevalence of metabolic syndrome and associated factors in the general population of Mongolia: A nationwide study.” 2. Abstract, and methods of main manuscript: I suggest exclude data of individuals <18 years old. They categorized as adolescents. So, interpretation of the findings in them can be different from other age groups. If you prefer to remain their data, I think it's better to analysis their data separately from other age-groups. We have excluded participants who were younger than 18 years old and the revised manuscript includes 5,695 participants who were 18 years old or older. 3. Introduction; please update Ref.7. Line 50: The reviewer suggested to update the reference of the definition and criteria of metabolic syndrome, but we think that the reference in our manuscript is the latest version (International Diabetes Federation. The IDF consensus worldwide definition of the metabolic syndrome. Brussels, Belgium: International Diabetes Federation; 2006). The reference number in Line 50 has been changed from 7 to 1, because we have changed the reference for the first sentence of the introduction section from “Deepa et al, Diabetes Metab Res Rev. 2007” to “The IDF consensus worldwide definition of the metabolic syndrome, 2006.” The first sentence explains about component of metabolic syndrome; therefore, “The IDF consensus worldwide definition of the metabolic syndrome, 2006” is more appropriate than the previous Ref. 1 (Deepa et al, Diabetes Metab Res Rev. 2007). 4. Insert date of the study in line 69 Line 69: We have added the year (2019) of the study as follows, “58.0% in adults ≥20 years old in a rural area in 2019.” 5. Method; please insert Ethical Committee approval code. Line 148: We have added the ethical approval number #53 in the sentence. 6. Results; It is missed expansion of some abbreviated words in the first use, such as HEC. Line 175: HEC was our mistake and it has been revised to “HCE. We have checked all abbreviations and added the full spelling for an abbreviation when it is used for the first time. 7. Please insert data of "central obesity" in all Tables. We have added “abdominal obesity (=central obesity)” in Tables 2 and 3. 8. For all tables, insert Statistical analysis test in the legend. We have added statistical analysis test in the footnote of Tables 2 and 3. 9. Please merge tables 3, and 4. We have merged Tables 3 and 4 into one table (Table 3). 10. Insert additional Tables, based on "urban/rural", "BMI", and "central obesity", separately. We have made three tables based on residence (rural and urban), BMI (normal, underweight, overweight, and obesity), and abdominal obesity (yes and no) and put them as S1-3 Tables in supporting information file. Supporting information captions has been added at the end of the manuscript file. 11. Discussion; The first paragraph should address the main findings. So, description of results and comparison with other studies should start from the second paragraph. Lines 270-277: We have revised the first paragraph of the discussion section and addressed the main findings as follows, “In this study, the prevalence of MetS was 37.4% in the general adult population of Mongolia. The MetS prevalence was significantly higher in women than men. The most prevalent MetS component was abdominal obesity in women but elevated FBG in men. Factors associated with MetS among both men and women were older age, low and moderate PA level, history of HT and DM, high BMI (overweight and obesity), and abdominal obesity. Ethnicity, education, income, current alcohol consumption were the associated factors only among men and current smoking and sufficient fruit and vegetable intake were only among women. These results showed that there were differences in the MetS prevalence, MetS component, and the associated factors among sexes.” 12. Ref.; nearly half of the Ref. are published on more than 10 years ago. Please update. We have revised 10 references that were published more than 10 years ago to more recent papers (published in 2015 or after). According to revision of the manuscript, reference numbers have been revised. The below table shows how we have revised references. We used EndNote (a software for reference manager) and revision of references and reference numbers cannot be retracted using the function of Track Change. Therefore, we have used red color for revised reference number and revised references in the reference section. Ref. Original　→　Revision 1 Deepa M, 2007 →The IDF consensus worldwide definition, 2006 5 Ford ES, 2005 →Yakoob MY, 2016 7 The IDF consensus worldwide definition, 2006 →Ref. number changed to 1. Ref. 8-21 →Ref. 7-20 22 NCEP expert panel on detection, evaluation,… , 2002 →Ref. number changed to 26 23 National Center for Public Health, 2020 →Ref. number changed to 21 24 Schneider JT, 2006 →(Ref. 22) Iwasa T, 2023. 25 Regitz-Zagrosek C, 2007 →(Ref. 23) Meloni A, 2023 26 Cornier MA, 2008 →(Ref. 24) Kautzky-Willer A, 2023 27 Kuk JL, 2010 →(Ref. 25) Tramunt B, 2020 28 Morales DD, 2008 →Changed to appropriate reference (Ref. 18) 29 Zago Z, 2004 →(Ref. 27) Li H, 2021 Ref. 30-36　→ Ref. 28-34 37 Fujita N, 2011 →(Ref. 35) Hirakawa M, 2015 38 Alkerwi A, 2009 →Erased due to Ref. 34 and Ref. 35 are enough for the sentence. 39 Yoon YS, 2004 →Erased due to Ref. 34 and Ref. 35 are enough for the sentence. Ref. 40-43→ Ref. 36-39 44 Halton TL, 2006 →(Ref. 40) Muraki I, 2016 45 Mozaffarian D, 2011 →(Ref. 41) Hojati A, 2024 46 Beulens JW, 2007 →(Ref. 42) Fung TT, 2016 13. Consider language editing for whole manuscript. In some sentences is observed numerous grammatical errors. We have asked a native English speaker who has a PhD to proofread the manuscript and we have revised our manuscript accordingly. Reviewer #2: 14. Criteria used for MetS are described based on (IDF) and Adult Treatment Panel (ATP) for estimating the prevalence of MetS, but in other parts only IDF criteria are used. I think ATP criteria may not be necessary. The paper just can only use IDF critera. We have erased the explanation about the criteria of ATP III and results based on the ATP III criteria in our manuscript and figures. 15. Table 2 provides no more information compared to Table 3. It could be potentially removed. This study focuses on differences between men and women in terms of metabolic syndrome and Table 3 shows the differences in factors associated with metabolic syndrome between the sexes. Table 2 shows the differences in the characteristics between male and female participants, and the characteristics differences were used to explain why differences were found in the prevalence of metabolic syndrome and associated factors between the sexes in the discussion section. Therefore, we would like to keep Table 2 in our manuscript. 16. Table 3, is the adjusted p-value calculated after adjustment with all variables? (more than 15 variables are introduced) Lines 139-142: We included all variables in Table 3 in multivariable logistic regression analyses. Before performing multivariable analysis, we confirmed there was no absence of a strong correlation among the independent variables. We also confirmed that the result of Hosmer-Lemeshow test was P > 0.05 in each model. We have added the following sentences in the method section, “Multivariable logistic regression analysis was performed on MetS using all the variables other than abdominal obesity. A correlation matrix was created to confirm the absence of strong correlation (γ > 0.80) among the independent variables. The result of the Hosmer-Lemeshow test of each model was P > 0.05. “ Lines 239-243: We have also added the result of Hosmer-Lemeshow test in the footnote of Table 3 as follows, “dMultivariable logistic regression analysis was performed including all variables in the table other than abdominal obesity (Hosmer-Lemeshow test: P = 0.280). eMultivariable logistic regression analysis was performed including all variables in the table other than sex and abdominal obesity (Hosmer-Lemeshow test: P = 0.607 [men] and P = 0.430 [women]).” Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0311320.r002
11 Jul 2024 Decision Letter - Mithun Sikdar, Editor PONE-D-23-37323R1Sex differences in the prevalence of metabolic syndrome and associated factors in the general population of Mongolia: A nationwide studyPLOS ONE Dear Dr. Yamamoto, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but need substantial revision in terms of English Editing. Therefore, we invite you to submit a revised version of the manuscript that addresses the issue. Please submit your revised manuscript by Aug 25 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, Mithun Sikdar 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. Additional Editor Comments: I am ready to accept the paper, provided it is revised with English Editing. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: 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: (No Response) ****** 6. Review Comments to the Author Reviewer #1: Dear Authors, All comments are adequately addressed, just please re-check sum of new estimations for each column. For example, sum of HTN data is incorrect. Best Regards, Reviewer #3: This is a simple straight forward Population Health data with adequate sample size representing the studied Population of Mongolia. Geographically and Ethnically the reported data seems to have the nationally standardized parameters for comparative reference which is in congruence to International classifications when computing for the Metabolic Syndrome. The overall results suggests no different but general observation and findings that females are more predisposed to MetS as compared to the male counterparts with Abdominal Obesity being more prevalent. Dietary assessment was perhaps the only limitation from this study where diet could have also played a vital role in the analysis of the reported study. Correlation tests and Regression models could have been tried and tested for a more analytical statistical interpretation. However, in simple text and language it is a good publication. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #3: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0311320.r003
Revision 2
21 Aug 2024 Author Response Response to the editor’s and reviewers’ comments We would like to thank the editor and reviewers for reviewing our manuscript. We have revised the manuscript according to your comments, which were very helpful. The revised manuscript has been proofread by a native English speaker. The revisions have been completed and our responses are as follows. Journal Requirements: 1. 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. We have added a new reference (Ref 21) according to the comment by Reviewer 1. In the manuscript, reference numbers of 21-42 have been revised to 22-43. We used EndNote (a software for reference manager) and revision of references and reference numbers cannot be retracted using the function of Track Change. Therefore, we have used red color for revised reference numbers and revised references in the reference section. Additional Editor Comments: 2. I am ready to accept the paper, provided it is revised with English Editing. The revised manuscript has been English proofread by a native English speaker. Therefore, there are many parts that have been revised according to the advice of the English proofreader. Reviewer #1: 3. All comments are adequately addressed, just please re-check sum of new estimations for each column. For example, sum of HTN data is incorrect. Lines 125-130, Table 2, and S1-3 Tables: Our study used the data from 5,695 participants who had no missing values for variables related to the MetS criteria, but some missing values for other variables. We have added the explanation about the missing values in the methods section as follows, “The total number of STEPS participants was 6,654 but 959 participants were excluded due to missing values on MetS measurement data. Finally, the data of 5,695 participants were analyzed in this study. There were missing values about ethnicity (n = 26), education (n = 1), marital status (n = 7), employment (n = 120), fruit and vegetable intake (n = 240), physical activity (n = 88), and body mass index (n = 1). The missing values were treated by multiple imputation method [21].” We have also added the number of participants for variables that had missing data in Table 2 and S1-3 Tables. Line 112: We have revised the sentence as follow, “….5,695 adult participants of the STEPS who were 18‒69 years old and whose data had no missing values for variables related to the MetS criteria.” We are very sorry that there were mistakes of numbers and percentages in tables. We have carefully checked all numbers and percentages in all tables and revised them correctly. Reviewer #3: 4. Dietary assessment was perhaps the only limitation from this study where diet could have also played a vital role in the analysis of the reported study. Lines 361-362: We have added a sentence in the paragraph of limitations as follow, “Dietary assessment was limited in this study, although diet may also play an important role in the development of MetS.” 5. Correlation tests and Regression models could have been tried and tested for a more analytical statistical interpretation. S4-6 Tables: According to the comment, we have performed two additional models of multivariate logistic regression, namely stepwise forward-selection and backward-selection. We have added three tables to show factors associated with MetS among all participants (S4 Table), men (S5 Table), and women (S6 Table) using the three models. Lines 143-147: In the methods section, we have added as follows, “In multivariable logistic regression analysis on MetS, three models were performed. In Model 1 (the forced-entry method), all the variables other than abdominal obesity were included. In Models 2 and 3 (the forward and backward stepwise selection method), variables were added when the P-value was less than 0.05 and removed when the P-value was over 0.1.“ Lines 272-279: In the results section, we have added as follows, “The results of multivariate logistic regression analyses for MetS among all participants, men, and women using three models are shown in S4-6 Tables. Older age (≥ 30 years old), low and moderate PA level, history of HT and DM, high BMI (overweight and obesity) were associated with MetS among all participants, men, and women in all three models. In addition, factors associated with MetS in the three models were Buriad ethnicity, residence in the central region and Ulaanbaatar, sufficient fruit and vegetable intake among all participants, current alcohol drinkers among men, and current smokers and sufficient fruit and vegetable intake among women.” Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0311320.r004
18 Sep 2024 Decision Letter - Mithun Sikdar, Editor Sex differences in the prevalence of metabolic syndrome and associated factors in the general population of Mongolia: A nationwide study PONE-D-23-37323R2 Dear Dr. Yamamoto 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, Mithun Sikdar Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0311320.r005
Formally Accepted
11 Oct 2024 Acceptance Letter - Mithun Sikdar, Editor PONE-D-23-37323R2 PLOS ONE Dear Dr. Yamamoto, 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. Mithun Sikdar Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0311320.r006

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