-->PONE-D-25-55420-->-->U-shaped Association Between Waist-to-Height Ratio and Microalbuminuria: A Cross-Sectional Analysis Conducted Within the Chinese Demographic-->-->PLOS One

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Academic Editor

PLOS One

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Additional Editor Comments:

Minor revision

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Reviewers' comments:

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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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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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-->5. Review Comments to the Author

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Reviewer #1: The article is well written, very rigorously done in terms of methodology, analysis, and conclusion. However, the area that needs little touch is the discussion section. The Authors quoted a lot of values in the discussion section, which are not necessary, though allowed where necessary but not generally encouraged. I recommend that the authors review the discussion section to remove all the "confidence intervals" and all the values that can be removed from the section. Otherwise, the article is well written and should be published.

Reviewer #2: A. Summary of the Study

This study investigates the U-shaped association between WHtR and microalbuminuria in a large cohort of 33,685 Chinese adults. Microalbuminuria, an early indicator of kidney damage, was assessed using UACR. The study utilized univariate and multivariate logistic regression models to analyze the data, complemented by Generalized Additive Models (GAM) for exploring non-linear associations. A significant non-linear U-shaped relationship between WHtR and microalbuminuria was identified, with higher risks at both low and high WHtR values. The study further explores subgroup analyses to examine factors like BMI and hypertension status in modifying this association. The findings emphasize the potential utility of WHtR as a clinical tool for identifying renal risks, particularly in populations without overt hypertension.

B. Major Evaluation

Originality and Research Contribution

This study presents an original investigation into the relationship between WHtR and microalbuminuria, a topic with limited prior research. The large sample size (33,685 participants) enhances the power of the findings and allows for more robust conclusions, especially regarding the non-linear (U-shaped) relationship between these variables.

While the topic itself is novel, the conclusion about the U-shaped association adds to existing knowledge but does not fundamentally challenge established theories. Further exploration of mechanisms behind this association could contribute more novel insights.

The authors could enhance the novelty by elaborating more on the physiological mechanisms that explain the U-shaped relationship.

Prior Publication Concerns

The study leverages a publicly available dataset from a previous study. While the secondary analysis is valid, it could raise concerns regarding redundancy if the data have already been heavily analyzed elsewhere.

The authors should explicitly compare their findings with previous studies that used similar datasets to clarify whether their conclusions are substantially new or merely an extension of prior work.

Technical and Methodological Quality

The study uses robust statistical methods, including multivariate logistic regression and GAM to assess both linear and non-linear relationships. The large sample size and comprehensive inclusion of potential confounders add to the rigor of the study design.

The cross-sectional nature of the study limits the ability to infer causality. Although this is acknowledged in the limitations, it remains a significant methodological constraint.

Future research could address this limitation by utilizing a longitudinal design to establish causal relationships more clearly.

Statistical Rigor

The use of multiple statistical models, including unadjusted and adjusted regression models and GAM, is appropriate and provides a thorough analysis of the data. The identification of a threshold effect in WHtR is a notable statistical contribution.

While the methods are well-described, the authors could have provided a clearer justification for the sample size beyond general statistical power. Additionally, handling of missing data is not explicitly mentioned.

Include more details on how missing data was handled and provide a justification for the chosen sample size, perhaps via a power analysis.

Validity of Conclusions

The conclusions logically follow from the results, with the authors adequately considering statistical significance and presenting well-supported claims.

While the authors state that their findings have important clinical implications, they may be overinterpreting the U-shaped relationship without addressing potential confounders like diet or genetic factors in more detail.

A more cautious tone could be adopted in discussing the clinical applicability of these findings until further studies confirm the mechanisms at play.

Major Issues Requiring Revision

Clarify the mechanisms behind the U-shaped relationship between WHtR and microalbuminuria. Address potential confounders more thoroughly, particularly lifestyle factors such as diet and physical activity.

Consider discussing the limitations of using a cross-sectional design more prominently in the conclusions section and suggest possible avenues for future longitudinal research.

Provide more details on the handling of missing data to increase the transparency of the statistical analysis.

Provide further justification for the sample size in the context of statistical power and include a power analysis.

Overall Recommendation

Minor Revision

While the manuscript presents valuable findings and adheres largely to the PLOS ONE criteria, it could benefit from a more detailed discussion of mechanisms, stronger causal interpretations, and more transparent handling of methodological limitations. These revisions would increase the manuscript’s robustness and clarity.

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Reviewer #1: Yes:Abdulrahman Ahmad

Reviewer #2: No

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U-shaped Association Between Waist-to-Height Ratio and Microalbuminuria: A Cross-Sectional Analysis Conducted Within the Chinese Demographic

PONE-D-25-55420R1

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Kind regards,

Santhi Silambanan, MD, DNB

Academic Editor

PLOS One