The metabolomic profile associated with clustering of cardiovascular risk factors—A multi-sample evaluation

Lars Lind; Johan Sundström; Sölve Elmståhl; Koen F. Dekkers; J. Gustav Smith; Gunnar Engström; Tove Fall; Johan Ärnlöv

doi:10.1371/journal.pone.0274701

Peer Review History

Original SubmissionJune 21, 2022
25 Jul 2022 Decision Letter - Ferdinando Carlo Sasso, Editor Transfer Alert This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present. PONE-D-22-17734THE METABOLOMIC PROFILE ASSOCIATED WITH CLUSTERING OF CARDIOVASCULAR RISK FACTORS – A MULTI-SAMPLE EVALUATIONPLOS ONE Dear Dr. Lind, 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. ============================== ACADEMIC EDITOR:The manuscript is interesting, but some issues need to be addressed by authors.============================== Please submit your revised manuscript by 2 weeks. 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, Ferdinando Carlo Sasso, PhD, MD Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional 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 2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information. Please also state whether your data was analysed anonymously or if you had access to identifying information. 3. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section. 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information Additional Editor Comments: The manuscript is interesting, but some issues need to be addressed by authors. Please, submit a revised version of your manuscript possibly within 2 weeks. [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: I Don't Know ****** 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: No ****** 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: I read with great interest the paper “The metabolomic profile associated with clustering of cardiovascular risk factors – a multi-sample evaluation" by Lind et al. The article is well written. Paper design must be improved. The article is logically divided into sections and subsections. Comments: 1. Line 64-65: please better specify the criteria for metabolic syndrome diagnosis. High blood pressure or in treatment, low HDL, high triglycerides levels… 2. Line 79-81: I suggest the author to modify accordingly: “Metabolomics have extensively been used to characterize the metabolic landscape of obesity and diabetes [6, 7]. Moreover, several studies have also been published on metabolomics in MetS [8]”. 3. The key role of insulin resistance in metabolic syndrome have been stressed in various research, and it has been mostly associated with visceral adipose. However, newer reports have reported the presence of insulin resistance in lean individuals, with NAFLD development, as well as increased cardiovascular disease development (doi: 10.3390/antiox10020270; doi: 10.37349/emed.2020.00019). Pathophysiological mechanisms are still not clear. Though, the suggested metabolomics could be implicated in this process. Is there any evidence in such individuals? Do you have any data? Reviewer #2: INTRODUCTION: It is too long and not well focused on main study background, hypothesis, literature gap, and aim. Please introduce the full diagnostic criteria for Metabolic Syndrome (MS), the criteria that you will use for all study. Add it in detail in the Methods. Please add more information about MS and cardiovascular diseases (CVDs) genesis and prognosis. Indeed, authors showed that MS could favor an arrhythmic status leading to enhanced automatism and higher rate of arrhythmic events with consequent refractoriness to ablative approaches and worse clinical outcomes (Cardiovasc Disord. 2014 Dec 6;14:176. doi: 10.1186/1471-2261-14-176). Please discuss this point. Again, the MS could cause over-inflammation and over-stretch of cardiac muscle (Front Physiol. 2018 Jun 26;9:758. doi: 10.3389/fphys.2018.00758), leading to worse prognosis by higher rate of arrhythmic atrial and ventricular events, ICDs’ therapies and hospitalizations. In this case, the MS could result in the compromising of functional status of heart failure patients treated with ICDs (Front Physiol. 2018 Jun 26;9:758. doi: 10.3389/fphys.2018.00758). Indeed, the MS could lead to cardiac electrophysiological alterations and clinical response in the treated patients affected by MS, by anormalities of sensing, (pacing) and impedance parameters (Medicine (Baltimore). 2017 Apr;96(14):e6558. doi: 10.1097/MD.0000000000006558). Please discuss this point and the adverse association between MS and HF. METHODS: Do you have number of ethical committee? Please add it. How did you calculate the study sample size? Please include a full description of incident atherosclerotic cardiovascular disease. RESULTS: I see a low percentage (0.2-12%) of diabetes medications. Please explain this point. DISCUSSION: Please focus the Discussion of 3 pages of description, and include according to authors (Curr Pharm Des. 2020;26(22):2565-2573. doi: 10.2174/1381612826666200213123029. ), the importance of over-inflammation in the pathogenesis and worse prognosis of CVDs, as in the case (see comments before) of MS. Please discuss it. ****** 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.0274701.r001
Revision 1
29 Aug 2022 Author Response Reviewer #1: I read with great interest the paper “The metabolomic profile associated with clustering of cardiovascular risk factors – a multi-sample evaluation" by Lind et al. The article is well written. Paper design must be improved. The article is logically divided into sections and subsections. Comments: 1. Line 64-65: please better specify the criteria for metabolic syndrome diagnosis. High blood pressure or in treatment, low HDL, high triglycerides levels… Reply: We have now better specified the criteria for metabolic syndrome diagnosis: “high blood pressure, increased waist circumference, high fasting glucose, low HDL-cholesterol and increased triglycerides.” (line 63-64) In addition, we have given the details used to define the 5 components in the methods section: high blood pressure, increased waist circumference, high fasting glucose, low HDL-cholesterol and increased triglycerides (line 139-143) “The five components were defined as follows: Blood pressure ≥ 130/85 mmHg or antihypertensive treatment, fasting plasma glucose ≥ 6.1 mmol/l or antidiabetic treatment, serum triglycerides ≥ 1.7 mmol/l, waist circumference > 102 cm in men and > 88 cm in women, HDL-cholesterol < 1.0 mmol/l in men and < 1.3 in women. Three of the mentioned five criteria should be fulfilled for MetS.” 2. Line 79-81: I suggest the author to modify accordingly: “Metabolomics have extensively been used to characterize the metabolic landscape of obesity and diabetes [6, 7]. Moreover, several studies have also been published on metabolomics in MetS [8]”. Reply: This part has now been changed according to your suggestion (line 74-76). 3. The key role of insulin resistance in metabolic syndrome have been stressed in various research, and it has been mostly associated with visceral adipose. However, newer reports have reported the presence of insulin resistance in lean individuals, with NAFLD development, as well as increased cardiovascular disease development (doi: 10.3390/antiox10020270; doi: 10.37349/emed.2020.00019). Pathophysiological mechanisms are still not clear. Though, the suggested metabolomics could be implicated in this process. Is there any evidence in such individuals? Do you have any data? Reply: This is a good idea! This lean insulin resistant group with NAFLD is very interesting. However, in the only study in which we have data on liver fat (the POEM study), only 3 subjects were classified as being lean and insulin resistant, so meaningful statistical evaluation of the metabolomic profile in this interesting group cannot be performed. We have now added a para on this idea in the discussion section, including the references you suggested (line 339-345): “In light of the present findings that the metabolomic profile being in common for the five MetS components is very similar to that seen in insulin resistance, it would be of interest to evaluate the metabolomic profile in lean subjects with insulin resistance, as this group often suffer from NAFLD and have an increased risk of CVD [35,36]. However, in the only study in which we have data on liver fat (the POEM study), only 3 subjects were classified as being lean and insulin resistant, so meaningful statistical evaluation of the metabolomic profile in this interesting group cannot be performed.” Reviewer #2: INTRODUCTION: It is too long and not well focused on main study background, hypothesis, literature gap, and aim. Reply: We have now shortened the introduction and tried to be more focused on the items you suggest. Please introduce the full diagnostic criteria for Metabolic Syndrome (MS), the criteria that you will use for all study. Add it in detail in the Methods. Reply: We have now given the details used to define the 5 components in the methods section: high blood pressure, increased waist circumference, high fasting glucose, low HDL-cholesterol and increased triglycerides (line 139-143) “The five components were defined as follows: Blood pressure ≥ 130/85 mmHg or antihypertensive treatment, fasting plasma glucose ≥ 6.1 mmol/l or antidiabetic treatment, serum triglycerides ≥ 1.7 mmol/l, waist circumference > 102 cm in men and > 88 cm in women, HDL-cholesterol < 1.0 mmol/l in men and < 1.3 in women. Three of the mentioned five criteria should be fulfilled for MetS.” Please add more information about MS and cardiovascular diseases (CVDs) genesis and prognosis. Indeed, authors showed that MS could favor an arrhythmic status leading to enhanced automatism and higher rate of arrhythmic events with consequent refractoriness to ablative approaches and worse clinical outcomes (Cardiovasc Disord. 2014 Dec 6;14:176. doi: 10.1186/1471-2261-14-176). Please discuss this point. Again, the MS could cause over-inflammation and over-stretch of cardiac muscle (Front Physiol. 2018 Jun 26;9:758. doi: 10.3389/fphys.2018.00758), leading to worse prognosis by higher rate of arrhythmic atrial and ventricular events, ICDs’ therapies and hospitalizations. In this case, the MS could result in the compromising of functional status of heart failure patients treated with ICDs (Front Physiol. 2018 Jun 26;9:758. doi: 10.3389/fphys.2018.00758). Indeed, the MS could lead to cardiac electrophysiological alterations and clinical response in the treated patients affected by MS, by anormalities of sensing, (pacing) and impedance parameters (Medicine (Baltimore). 2017 Apr;96(14):e6558. doi: 10.1097/MD.0000000000006558). Please discuss this point and the adverse association between MS and HF. Reply: We have included a new paragraph in the discussion section discussing the issues of hyperinflammation, ICD, cardiac stretch and heart failure in relation to MetS with three new references mentioned by you. However, since you wanted to reduce the discussion part to three pages, this added paragraph had to be kept short (line 315-322):” MetS has been linked to the major cardiovascular diseases, myocardial infarction, stroke and heart failure [9]. MetS has also been linked to other adverse cardiovascular conditions, such as a poor outcome in patients affected by outflow tract premature ventricular contractions treated by catheter ablation [26] and a proarrythmogennic state in heart failure patients treated with an internal cardioverter defibrillator (ICD) [27]. An increased level of inflammation [28] together with over-stretch of cardiac muscle and fibrosis development due to MetS could lead to cardiac electrophysiological alterations, a poor myocardial performance and clinical outcome in the patients affected by MetS [29].” METHODS: Do you have number of ethical committee? Please add it. Reply: This has now been added (line 102): “Dnr 2021-00134” How did you calculate the study sample size? Reply: No formal power calculation was performed. The study is however the largest study (>11,000 individuals) performed regarding a large set of metabolites (n=791) and MetS, so the power to find significant association is higher than in the previous literature. We have now added to the discussion (line 359-362):” No formal power calculation was performed. The study is however the largest study (>11000 individuals) performed regarding a large set of metabolites (n=791) and MetS, so the power to find significant associations was substantially higher than in the previous literature.” Please include a full description of incident atherosclerotic cardiovascular disease. Reply: We have now added more information regarding the evaluation of incident atherosclerotic cardiovascular disease. If you like us to add some additional information, please let us know.” Using data from the Swedish cause of death and in-hospital care registers, we defined a combined end-point for atherosclerotic CVD being either fatal or non-fatal acute myocardial infarction or ischemic stroke (ICD-10 codes I20 or I63-I66). Incident cases of atherosclerotic CVD were only investigated in the EpiHealth sample, since the other samples had yet too short follow-up period. The median follow-up period in EpiHealth was 8.6 years. The censor date of the follow-up was Dec 31, 2020.” (line 166-171) RESULTS: I see a low percentage (0.2-12%) of diabetes medications. Please explain this point. Reply: This wide range in diabetes prevalence is due to the fact that the range in age is large between the samples. The diabetes prevalence in the different age-groups are similar to other Swedish cohort studies, so from our perspective the percentage (0.2-12%) of diabetes medications is not surprising. DISCUSSION: Please focus the Discussion of 3 pages of description, and include according to authors (Curr Pharm Des. 2020;26(22):2565-2573. doi: 10.2174/1381612826666200213123029. ), the importance of over-inflammation in the pathogenesis and worse prognosis of CVDs, as in the case (see comments before) of MS. Please discuss it. Reply: We have now condensed the discussion to three pages. We have now discussed the proinflammatory state as a driver of CVD in subjects with MetS, as commented before. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0274701.r002
2 Sep 2022 Decision Letter - Ferdinando Carlo Sasso, Editor The metabolomic profile associated with clustering of cardiovascular risk factors – a multi-sample evaluation PONE-D-22-17734R1 Dear Dr. Lind, 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 for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, 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, Ferdinando Carlo Sasso, PhD, MD Academic Editor PLOS ONE Additional Editor Comments (optional): The authors addressed all issues raised by reviewers. No further comments. 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 #2: 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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes 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 #1: Yes Reviewer #2: 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 #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 #1: The paper has much improved and the authors managed to respond to all the issues I raised. The paper can be further processed for publication. Reviewer #2: The authors revised the article according to reviewers' comments. In my opinion, you could be accepted for a possible pubblication in the journal. ****** 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 #2: No ******** https://doi.org/10.1371/journal.pone.0274701.r003
Formally Accepted
6 Sep 2022 Acceptance Letter - Ferdinando Carlo Sasso, Editor PONE-D-22-17734R1 The metabolomic profile associated with clustering of cardiovascular risk factors – a multi-sample evaluation Dear Dr. Lind: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. 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 plosone@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 Professor Ferdinando Carlo Sasso Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0274701.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .