-->PONE-D-25-67473-->-->Association between occupational sedentary behavior and metabolic syndrome and related diseases in males: A cross-sectional study-->-->PLOS One

Dear Dr. Shaofan Weng,

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Sanaullah Sajid, Ph.D.

Academic Editor

PLOS One

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Additional Editor Comments (if provided):

Here are the missing comments from Reviewer 3.

While the study utilizes a robust sample size of 2,055 male workers, there are critical flaws in how the data is interpreted and reported specifically a direct contradiction between the statistical results and the abstract's conclusions.

1. The abstract concludes that “Occupational sedentary behavior in males is associated with higher prevalence of metabolic syndrome...”. However, this is demonstrably false based on the study’s own data. In the results section of the abstract, the authors report an Odds Ratio for MetS of 1.05 (95%CI: 0.85-1.29). Since the 95% confidence interval crosses 1.0, this is not a statistically significant finding.

2. The abstract must be rewritten to accurately reflect that occupational sedentary behavior was associated with specific components of metabolic syndrome (hypertriglyceridemia, hypoalphalipoproteinemia, and central obesity), but not overall MetS itself.

3. The introduction effectively sets up the premise, noting that occupational sedentary behavior is distinct from leisure-time sedentary behavior because it is mandatory and uncontrollable.

4. The authors should briefly introduce why bus drivers and sanitation workers were specifically chosen as the proxies for sedentary and non-sedentary groups, as these two professions entail vastly different environmental and stress exposures.

5. The fundamental flaw in the study design is comparing bus drivers (sedentary) to sanitation workers (non-sedentary). These two groups differ in many ways beyond just sitting time. The authors must acknowledge that bus driving involves high psychological stress, shift work, and vibration, while sanitation work involves heavy physical exertion and high exposure to outdoor pollutants.

6. While the authors adjusted for age, ethnicity, marital status, education level, smoking status, drinking status, length of work, and weekly working hours, they failed to measure or adjust for two massive confounders:

7. Caloric intake and dietary habits are primary drivers of MetS.

8. A sanitation worker might rest after work, while a bus driver might exercise. Without adjusting for non-occupational physical activity, isolating the effect of occupational sedentariness is highly problematic.

9. The data shows that the sedentary group had a lower prevalence of hypertension (44.1% vs. 54.6%) and hyperglycemia (23.8% vs. 29.4%) compared to the non-sedentary group. In the main text, the authors write: Interestingly, despite no significant difference was observed between the groups (P=0.681), the trend of a higher prevalence of MetS in occupational

sedentary group.. Reporting a non-significant result as a trend of higher prevalence is statistically inappropriate and must be removed. 10. Table 3 confirms that MetS is not significantly associated with sedentary behavior across Model 1 (p=0.681), Model 2 (p=0.196), or Model 3 (p=0.285). The manuscript must be revised

overall to remove claims that a direct association with overall MetS was found.

11. The authors attempt to explain the lower rates of hypertension and hyperglycemia in bus drivers by citing workplace regulations namely, that bus drivers undergo strict blood pressure monitoring and those failing to meet standards are prohibited from driving. This is a textbook example of the Healthy Worker Survivor Effect. Because sick bus drivers are removed from the population, the remaining drivers appear artificially healthier in these metrics. This severely limits the validity of comparing these two specific cohorts and must be explicitly detailed as a major limitation.

12. The discussion regarding skeletal muscle activity, lipoprotein lipase (LPL), and interleukin-6 (IL-6) is well-supported and provides a good biological mechanism for the lipid abnormalities observed. The limitations section currently notes the cross-sectional design and self-reported questionnaire variables. It must be expanded to explicitly state the unmeasured confounders (diet, non-work physical activity) and the immense baseline differences between the specific occupations chosen.

There are a few papers that align with the physiological and metabolic aspects of the manuscript. We suggest to appropriately integrate them:

• Sarfraz, M., Sajid, S., & Ashraf, M. A. (2016). Prevalence and pattern of dyslipidemia in hyperglycemic patients and its associated factors among Pakistani population. Saudi journal of biological sciences, 23(6), 761-766.

Where: In the Discussion section. The authors discuss the prevalence of hypertriglyceridemia and hyperglycemia in their cohorts. You use this paper to contextualize the regional prevalence of dyslipidemia and how it clusters with hyperglycemia in Asian populations.

• Abbas, G., Salman, A., Rahman, S. U., Ateeq, M. K., Usman, M., Sajid, S., ... & Younas, T. (2017). Aging mechanisms: linking oxidative stress, obesity and inflammation. Matrix Sci. Med, 1(1), 30-33.

Where: In the Discussion section regarding the subgroup analysis. The authors note a significant interaction between age (>55 years) and central obesity. You use this paper to help

them explain the biological mechanisms

, specifically how aging and inflammation exacerbate obesity-related metabolic dysfunction

• Toor, I. F., Sajid, M., & Sajid, H. U. (2024). Molecular Mechanisms of Diabetes Mellitus. Fundamentals of Cellular and Molecular Biology, 156-176.

Where: In the Introduction or Discussion. The authors should expand on the long-term consequences of the hyperglycemia and metabolic syndrome observed in their study.

These recent publications could serve as up-to-date references on the molecular progression and management of diabetes.

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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: Partly

Reviewer #3: Partly

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

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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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 association between occupational sedentary behavior and metabolic syndrome was not statistically significant; therefore, it is recommended that this relationship be revised accordingly in both the abstract and the conclusion.

In addition, the potential for residual confounding should be considered, given the substantial differences between occupational groups, including socioeconomic status and work-related stress. Possible misclassification bias may also exist due to the classification of sedentary behavior based solely on occupational categories.

Furthermore, there is an inconsistency regarding the version of the Chinese diabetes guidelines cited for the definition of metabolic syndrome in the study, which should be corrected.

Reviewer #2: A primary concern is the cross-sectional study design, which limits causal inference; the authors must ensure the discussion consistently interprets findings as associations rather than directional relationships. Regarding sampling and selection bias, the recruitment strategy needs a more detailed explanation, particularly acknowledging how online or group-based recruitment impacts the sample's representativeness of the broader population. Furthermore, the validity of the survey instrument must be addressed by describing any pilot testing or reliability assessments, or by explicitly acknowledging the lack of formal validation as a study limitation.

The statistical analysis section also requires further technical detail. The authors should clarify their regression modeling strategy, specifically outlining variable selection criteria, confounder adjustment, reference categories, multicollinearity assessments, and model diagnostics to ensure all relevant confounders were addressed. The authors must ensure that raw anonymized data are accessible, either as supplementary material or via a public repository. Finally, the limitations section should be expanded to include recall bias, residual confounding, and the reliance on self-reported diagnoses without objective biomarkers. Minor improvements are also needed to ensure consistency between percentages and raw numbers, refine the formatting of p-values and confidence intervals, and streamline the discussion to improve flow and reduce repetition.

Reviewer #3: While the study utilizes a robust sample size of 2,055 male workers, there are critical flaws in how the data is interpreted and reported specifically a direct contradiction between the statistical results and the abstract's conclusions.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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Submitted filename: Recommendation.pdf

Association between occupational sedentary behavior and metabolic syndrome and related diseases in males: A cross-sectional study

PONE-D-25-67473R1

Dear Dr. Weng,

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,

Sanaullah Sajid, Ph.D.

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments: