PONE-D-24-56824Impact of Lifestyle Behaviors on the Development of Lifestyle Diseases: A Retrospective Cohort StudyPLOS ONE

Dear Dr. Saitoh,

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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We look forward to receiving your revised manuscript.

Kind regards,

Mulu Tiruneh

Academic Editor

PLOS ONE

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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 If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references.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 If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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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

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

Reviewer #1: Yes

Reviewer #2: Yes

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

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

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The manuscript presents a comprehensive and well-executed study on the impact of lifestyle behaviors on the development of lifestyle diseases using a robust dataset from a large retrospective cohort. The research is technically sound, with an appropriately designed methodology and statistical analysis that strengthens the reliability of the findings. By utilizing logistic regression models with stepwise adjustments, the study effectively accounts for key confounders, including age, sex, BMI, and laboratory parameters. The large sample size of over 47,000 participants ensures sufficient statistical power, and the stratified analysis of disease outcomes enhances the depth of the results.

The statistical analysis is rigorous, employing multivariate models that explore the independent effects of lifestyle behaviors. However, additional details on multicollinearity diagnostics, such as reporting variance inflation factors (VIFs), would further validate the results. While the use of odds ratios with confidence intervals is appropriate, the discussion could benefit from emphasizing the clinical relevance of statistically significant findings. For instance, while smoking and weight gain emerged as common risk factors across multiple diseases, it would be helpful to contextualize these findings within public health interventions.

One intriguing finding is the protective association between skipping breakfast and diabetes, which contradicts much of the existing literature. While this result is novel, it warrants further exploration, possibly through sensitivity or subgroup analyses to account for regional dietary habits or meal composition. The manuscript would also benefit from a discussion on residual confounding, as factors like socioeconomic status or genetic predispositions were not included in the analysis.

Although the reliance on self-reported data is acknowledged as a limitation, it introduces potential biases such as recall and social desirability bias. A more detailed discussion on how these biases may have influenced the results would strengthen the manuscript. Additionally, the study does not account for changes in lifestyle behaviors during the follow-up period, which may affect the observed associations. Future research should consider longitudinal tracking of behavioral changes to provide a more nuanced understanding of their effects.

In terms of generalizability, the study is limited to a specific region in Japan, and the findings may not be directly applicable to other populations with different cultural, dietary, or healthcare contexts. The authors should discuss how similar studies in other regions could validate and expand upon these results.

In conclusion, this manuscript is a valuable contribution to the field of public health and provides actionable insights into the relationship between lifestyle behaviors and lifestyle diseases. With minor improvements in the discussion of limitations, clinical relevance, and generalizability, this study could serve as a strong foundation for public health strategies aimed at mitigating the burden of lifestyle diseases.

Kudos to authors and team member in developing a very good project and article.

Reviewer #2: Strengths:

The study addresses a critical public health issue based on a large longitudinal dataset.

The application of the logistic regression model is appropriate, and the results are presented clearly.

The supplementary materials included herein enhance the reproducibility of the study.

Suggestions for Improvement:

Explain why the analysis excluded individuals who had multiple checkups. If this is done, selection bias could be introduced into the analysis because such persons may differ in some systematic way from those included in the analysis.

Address the multicollinearity issue in the logistic regression models by reporting the VIF values and discussing how the overlapping lifestyle behaviors were dealt with.

Simplify and visualize results using plots of bar charts or heat maps that give in one glance several key findings of Table 1 and Table 2.

The findings should be discussed for their clinical significance. However, not every statistically significant association is clinically significant and may deserve further consideration in terms of modest effect size, such as the identified one for fast eating and diabetes, with an OR of 1.17. Expand the discussion of limitations. Acknowledge potential biases (e.g., recall bias, selection bias) and the limited generalizability of the findings.

Highlight practical implications: Describe how such findings might be used to inform public health interventions or policy.

Additional Comments:

The negative relation of breakfast omission with diabetes appears intriguingly protective, with an odds ratio of 0.70, which also goes against previous reports. This might be discussed more elaborately in the discussion part, considering either regional dietary habits or confounding. Where relevant, for example, when referring to the "standard questionnaire" or cutoff values, the manuscript should refer explicitly to supplementary tables.

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Reviewer #1: No

Reviewer #2: Yes:  Kola Adegoke

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Attachments

Attachment

Submitted filename: COMMENTS ON ARTICLE.pdf

PONE-D-24-56824R1Impact of Lifestyle Behaviors on the Development of Lifestyle Diseases: A Retrospective Cohort StudyPLOS ONE

Dear Dr. Saitoh,

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 Jul 04 2025 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,

Mulu Tiruneh

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

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

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

Reviewer #2: Partly

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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: No

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #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: We appreciate the chance to comment on the revised manuscript entitled "Impact of Lifestyle Behavior on Lifestyle Disease Development: A Retrospective Cohort Study." The study is well-timed and methodologically rigorous, using a large dataset to assess self-reported lifestyle behavior predictors for the development of metabolic syndrome, diabetes, hypertension, and dyslipidemia. The statistical strategy, which involves logistic regression models and stepwise adjustments, is suitable and well-explained. The authors enhance the manuscript further through a more explicit elaboration of rationale and substantiation for the relationship between behavioral surveillance and prediction of public health risk.

However, I want to voice my concern over the findings' interpretability and generalizability. The implication that skipping breakfast is linked to less diabetes contradicts the literature. It suggests a more elaborate sensitivity analysis or other explanations, such as reverse causation or bias for reporting. Although the data are extensive, the sample is geographically and demographically restricted (only insured adults within Gunma Prefecture), and this may be better highlighted. The confounding effect from unmeasured lifestyles or socioeconomic factors (e.g., sleep, work, job status) could also be mentioned.

Finally, whilst the manuscript is composed well and readable, the Data Availability Statement is inconsistent with PLOS’s open data policy. Please specify a means for de-identified data availability through a recognized repository or institutional arrangements. I suggest minor revisions and changes to meet these issues and enhance the manuscript's contribution to the evidence base for preventive health actions through behavioral data.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #2: Yes:  Kola Adegoke

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[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.

Impact of Lifestyle Behaviors on the Development of Lifestyle Diseases: A Retrospective Cohort Study

PONE-D-24-56824R2

Dear Dr. Saitoh,

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.

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Kind regards,

Mulu Tiruneh

Academic Editor

PLOS ONE

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