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. 2023 Feb 14;18(2):e0277185. doi: 10.1371/journal.pone.0277185

Atherogenic dyslipidemia and associated risk factors among hypertensive patients of five health facilities in Northeast Ethiopia

Ousman Mohammed 1,*, Ermiyas Alemayehu 1, Endris Ebrahim 1, Mesfin Fiseha 1, Alemu Gedefie 1, Abdurrahman Ali 1, Hussen Ebrahim 1, Mihret Tilahun 1
Editor: Paolo Magni2
PMCID: PMC9928121  PMID: 36787318

Abstract

Background

One of the major risk factors for cardiovascular disease is atherogenic dyslipidemia. There was, however, little information available in Ethiopia. Therefore, the purpose of this study was to estimate the prevalence of atherogenic dyslipidemia and related risk factors in Northeast Ethiopian hypertension patients.

Materials and methods

A systematic random sampling technique was used to perform a cross-sectional study at an institution with 384 chosen participants. A structured questionnaire was used to collect the socio-demographic, anthropometric, lifestyle, and clinical characteristics of the respondents. Student’s t-test, Mann-Whitney test, and Pearson’s Chi-square test were employed to compare groups based on the type of data. Furthermore, Bivariate and multivariable logistic regression analyses were performed to identify factors independently associated with dyslipidemia. Crude and adjusted odds ratios and their corresponding 95% Confidence Intervals (CI) were computed. In all cases, statistical significance was declared at p <0.05.

Results

The majority (93.2%; 95%CI: 90.6–95.6) of patients had at least one atherogenic dyslipidemia. The prevalence of elevated total cholesterol (TC), elevated triglyceride (TG), raised low-density lipoprotein cholesterol (LDL-c), and reduced high-density lipoprotein cholesterol (HDL-c) were 47.7%, 50.3%, 44.3%, and 59.6%, respectively. Being≥ 40 years were at higher risk for having elevated levels of TC (AOR: 3.22, 95% CI: 2.40–4.32), TG (AOR: 2.30, 95% CI: 1.61–3.79), and LDL-c (AOR: 4.68, 95% CI: 2.0–10.95) than those who were below 40years. Obese participants were more likely to have high concentrations of TC (AOR: 2.57, 95%CI: 2.10–3.22), LDL-c (AOR: 3.13, 95% CI: 1.97–5.10), HDL-c (AOR: 2.71, 95% CI: 1.77–4.58), and TG (AOR: 2.23, 95%CI: 1.79–4.16).

Conclusion

This study revealed that a high prevalence of atherogenic dyslipidemia. Thus, to prevent atherogenic dyslipidemia, it is crucial to create routine blood lipid testing programs and carry out suitable intervention programs focused on risk factor reduction.

Introduction

Globally, it is estimated that one billion adults live with hypertension; this figure is predicted to be more than 1.5 billion by the year 2025. Furthermore, at least 45% of fatalities from heart disease and 51% of deaths from stroke were caused by hypertension [1]. Due to inadequate levels of therapy and management of hypertension in Africa, the high burden of hypertension is the main cause of mortality and morbidity linked with cardiovascular disorders globally [2–5]. In Ethiopia, hypertension is one of the most common public health burdens. The pooled prevalence of hypertension in the Ethiopian population was calculated to be 19.6 percent [6].

More than half of the 17.4 million fatalities per year that occur worldwide are caused by cardiovascular illnesses, which are connected to hypertension. The research suggests that responsible authorities should pay more attention to the cardiovascular health of African populations living in both rural and urban areas [7, 8]. According to the etiology and prognosis of atherosclerosis and cardiovascular disease (CVD), hypertension and atherogenic dyslipidemia frequently coexist [9–12]. One of the primary risk factors for the development of atherosclerosis is atherogenic dyslipidemia. The prevalence of cardiovascular disorders has increased as a result of the expansion of atherosclerosis. Thus, it is clear that the frequent co-occurrence of hypertension, atherosclerotic dyslipidemia, and other metabolic abnormalities in patients increases the risk of heart failure and CVD-related morbidity and death [13–16].

Currently, CVD is one of the most common causes of death worldwide and is on the rise [17]. Compared to people with normal lipid levels, those with atherogenic dyslipidemia are more likely to develop CVD [18]. High levels of total cholesterol (TC), hypertriglyceridemia, low-density lipoprotein cholesterol (LDL-c), lower HDL-c, and an increased atherogenic index TC/HDL-c ratio are all indicators of atherogenic dyslipidemia [19–22]. Atherosclerosis, which is known as the main risk factor for stroke, peripheral vascular disease, and coronary heart disease (CHD), is made more likely by elevated blood levels of certain lipids [23]. LDL-c may have an impact on the onset of atherosclerosis [22]. On the other hand, HDL-c plays a role in the reverse transport of cholesterol, which decreases the risk of atherosclerotic CVD [22, 24].

Patients with coexisting cardiovascular risk factors, such as hypertension, have a substantially greater prevalence of dyslipidemia [25, 26]. A number of risk factors were linked to dyslipidemia among hypertension patients, according to empirical data from earlier literature. These risk variables included sedentary behavior, age, gender, obesity, smoking, diabetes, and a poor diet of fruits and vegetables [27, 28]. Although non-healthy food and people’s behaviors are linked to roughly 80% of dyslipidemia [29], this percentage is still high. In addition, Kifle Z et al. and Hirigo A et al., respectively, observed high rates of dyslipidemia among Ethiopian hypertensive patients (48.4% and 90.8%) [27, 28].

Evidence suggested that the rising prevalence of atherogenic dyslipidemia and hypertension in patients may significantly deteriorate their state of health [10, 12, 30, 31]. In the majority of developing nations, including Ethiopia, CVD-related diseases and hypertension have recently become major public health issues [3, 4, 27]. There were few data on the prevalence of dyslipidemia and related variables in hypertension patients in Ethiopia, despite its high prevalence and related complication in this population. To our knowledge, we found only a few published studies that were conducted in one healthcare setting. As a result, they might not be representative of the general public. The current study’s objective was to evaluate atherogenic dyslipidemia and the factors that contribute to it among hypertensive patients at five healthcare facilities in northeast Ethiopia.

Materials and methods

Study design, setting and period

The current institution-based cross-sectional study was conducted at the selected hospitals in Dessie town from June to October 2021. The town has a cold temperature and is located on a mountain crest. Its entire area is 15.08 km2, and its distance from Addis Ababa, the county headquarters, and Bahir Dar, the capital of the Amhara regional state, respectively, is 401 km and 471 km. Eight health facilities, three private general hospitals, five higher private clinics, one general hospital, one comprehensive specialized hospital, and one general hospital are all located in Dessie town and provide medical services to the surrounding areas [32]. For the purpose of this study five (namely, Dessie comprehensive specialized hospital, Borumeda general hospital, Selam general hospital, Ethio general hospitals, and Bati general hospitals) health facilities that provide chronic diseases services were selected.

Study population and legibility criteria

Patients with hypertension who visited the chronic department of particular hospitals during the study period were included. Based on a single population proportion calculation and a 48.4% overall prevalence of dyslipidemia in hypertension patients, the sample size was determined [27]. With a 95% confidence level, the expected margin of error (d) was calculated at a level of 0.05. Thus, the calculated sample size was 384. The overall sample size was appropriately distributed based on the number of registered hypertension patients in each healthcare setting because the data were gathered from five distinct healthcare facilities. A methodical random sampling strategy was used to choose the respondents. All volunteer hypertensive patients age ≥18years-old who had a regular follow-up were eligible in the 1study. However, physiological and pathological factors that could alter serum lipid profiles, such as pregnancy, taking lipid-altering drugs, and antihyperlipidemic medications, were excluded because the study was designed to assess dyslipidemia. Moreover, critically ill and those with mental problems and unable to communicate were excluded from the study.

Data collection and quality control

Data were collected through a structured, validated, and pretested face-to-face interviewer-administered questionnaire. The questionnaire contained information on socio-demographics, history of co-morbidity, the habit of physical exercise, behavioral habits (alcohol consumption and smoking), etc. Two well-trained data collectors (BSc nurses) were recruited for each health facility. They were given training for two days on the method of extracting the needed information, how to fill the information on a structured questionnaire, and the ethical aspect of approaching the participants as well as the aim of the study and the contents of the instruments. The data collection material was pre-tested on 10% of the sample size to check completeness, consistency, and applicability and was modified accordingly. The researchers were making spot-checks of at least 5 questionnaires per day. Reviewing the completed questionnaire by the data collectors ensures completeness and consistency of the information that was collected. Quality control was carried out during the pre-analytical, analytical stages, and post-analytical phases. Furthermore, patient samples were evaluated alongside analytical stage quality control checks, which included quality control materials (Normal, Low, and High) to detect if analytic errors had occurred.

Anthropometric measurement and biochemical analysis

Following a standardized protocol, weight, and height were measured by trained collectors. Standing heights were taken without shoes to the closest 0.1 cm using well-situated stadiometers. The weights were measured to the closest 0.1 kg using a digital balance. Weights were measured without heavy clothes and shoes, while heights were measured without shoes to get an accurate measurement. After 5 minutes of rest, blood pressure was checked in triplicate, with subsequent readings taken 5 minutes apart. Additionally, body mass index (BMI) was calculated as the product of weight (kg) and height (meters), squared (kg/m2). Participants with a BMI lower than 18.5 kg/m2 were considered as underweight; between 18.5 and 24.9 kg/m2 as normal; between 25.0 and 29.9 kg/m2 as overweight and 30.0 kg/m2 and above as obese [33]. Waist circumference (WC) was measured at the level of the iliac crest and the level of the umbilicus in cm to evaluate abdominal obesity, and raised WC was defined as ≥94 cm for men and ≥80 cm for women [34]. The average values from each set of three duplicate anthropometric measurements were utilized to conduct the analysis.

After obtaining consent, around 5 ml of venous blood sample was collected after overnight fasting for TG, HDL-c, LDL-c, and TC tests. The blood sample was clotted for 30 minutes. Then, the serum sample was separated from the Nunc tube following centrifuged for 5 minutes at 4000 revolutions per minute. Lipid profile parameters were analyzed with a fully automated clinical chemistry analyzer using the direct endpoint enzymatic process. All samples were analyzed within 24 hours with the same analyzer to minimize assay variation. Before sample analysis, the machine was checked using controls and blank on a daily basis. The cut-offs for abnormal serum lipid levels were: ≥200 mg/dL for total cholesterol (TC), for triglyceride (TG) concentrations of ≥150 mg/dL, for (LDL-c)>130 mg/dL, and HDL-c <40 mg/dL based on the National Cholesterol Education Program (NCEP) reference limits. According to NCEP the applied the cut-off value for TC/HDL-c ratio was ≥5. Hence, according to the NCEP guidelines, individuals should have at least one of the lipid parameters that become abnormal to be categorized under the presence of dyslipidemia [22].

Data analysis

The statistical analysis was performed using the SPSS version 23 statistics package for social sciences. Data were summarized as means/median ± standard deviation and proportion (percentages) for continuous and qualitative data, respectively. Comparisons between groups were done using Student’s t-test and X2, respectively, for continuous and categorical data respectively. Besides, the normality of the continuous variables was checked and the Mann-Whitney test was used for skewed distribution. Furthermore, bivariate and multivariable logistic regression analyses were performed to identify factors independently associated with dyslipidemia. Crude and adjusted odds ratios and their corresponding 95% Confidence Intervals (CI) were computed. In all cases, statistical significance was declared at p <0.05.

Ethics approval and consent to participate

The study was approved by the Institutional Review Board of Wollo University, College of Medicine and Health Sciences, and ethical clearance was obtained. The appropriate health facilities received official letters of collaboration, and consent was acquired. Prior to collecting any data, each study participant gave their written informed consent after being fully aware of the study’s protocols and the involvement was completely voluntary.

Results

Prevalence of dyslipidemia according to socio-demographic characteristics of study participant’s

A total of 384 respondents were included in the current study with a 100% response rate. Among them, 202 (52.6%) were men. More than two-thirds (67.2%) of the hypertensive individuals were 40 years and above, while 32.8% were in the age range of 18–39 years with a mean age of 46.5±12.7 years. Similarly, more than half 213(55.5%) of the hypertensive peoples were permanent residents of urban areas. Of the total hypertensive individuals, the highest of prevalence lipid abnormalities was seen for reduced HDL-C level (59.6%), followed by elevated triglycerides (50.3%), elevated total cholesterol (47.7%), and elevated LDL-C (44.3%) in both sexes. Likewise, the magnitude of all serum lipid profile derangements was significantly different across gender and age groups (P<0.05). A higher percentage of female hypertensive individuals had elevated lipid profiles (P<0.05). Furthermore, the urban residence participants had significantly higher serum lipid abnormalities of 122(57.3%), 113(55.0%), 119(55.9%), and 133(62.4%) for TC, TG, LDL-c, and HDL-c respectively (P <0.05) (Table 1).

Table 1. Distribution of dyslipidemia by socio-demographic characteristics of hypertensive patients in Northeast Ethiopia, 2021 (n = 384).

Variables Frequency (%) TC ≥ 200 mg/dL N (%) TG ≥ 150 mg/dL N (%) LDL-c> 130 mg/dL N (%) HDL-c < 40 mg/dL N (%)
Age in year 18–39 126(32.8) 18(14.3) 51(40.5) 21(16.7) 64(50.8)
≥40 258(67.2) 165(64.0) 142(55.0) 149(57.8) 165(64.0)
P-value <0.001 0.001 <0.001 0.02
Sex Female 182(47.4) 92(50.5) 108(59.3) 87(47.8) 119(65.4)
Male 202(52.6) 91(45.1) 85(42.1) 83(41.1) 110(55.4)
Combined 384 (100) 183 (47.7) 193 (50.3) 170 (44.3) 229 (59.6)
P-value 0.02 0.03 0.01 0.03
Residence Urban 213(55.5) 122(57.3) 113(55.0) 119(55.9) 133(62.4)
Rural 171(44.5) 81(47.4) 80(46.8) 78(45.6) 96(56.1)
P-value 0.01 0.004 0.03 0.02
Marital status Single 102(26.6) 32(31.4) 45(44.1) 33(32.4) 53(52.0)
Married 212(55.2) 111(52.4) 109(51.4) 99(46.7) 132(62.3)
Divorced 45(11.7) 26(57.8) 22(48.9) 15(33.3) 26(57.8)
Widowed 25(6.5) 14(56.0) 17(68.0) 13(52.0) 18(72.0)
P-value 0.52 0.87 0.03 0.19
Occupations Government 114(29.7) 45(39.5) 54(47.4) 37(32.4) 67(58.8)
Nongovernment 63(16.4) 28(44.4) 36(57.1) 25(39.7) 34(54.0)
Self employed 105(27.3) 53(50.5) 55(52.4) 51(48.6) 71(67.6)
Student 11(2.9) 2(18.2) 4(36.4) 3(27.3) 6(54.5)
Farmer 91(23.7) 55(60.4) 44(48.4) 54(59.3) 51(56.0)
P-value 0.009 0.23 0.05 0.21
Monthly income in ETB >3000 122(31.8) 56(45.9) 58(47.5) 54(44.3) 70(57.4)
2001–3000 99(25.8) 47(47.5) 52(52.5) 43(43.4) 62(50.8)
1000–2000 86(22.4) 44(51.2) 47(54.6) 33(38.4) 51(59.3)
<1000 77(20.1) 36(46.8) 36(46.8) 40(51.9) 46(59.7)
P-value 0.89 0.14 0.53 0.89
Educational status Secondary and above 67(17.4) 28(41.8) 31(46.3) 23(34.3) 33(49.2)
Primary 132(34.4) 57(43.2) 66(50.0) 48(36.4) 80(60.6)
Illiterate 185(48.2) 96(52.0) 90(48.6) 93(50.3) 112(60.5)
P-value 0.27 0.84 0.21 0.72
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Note: TC: Total cholesterol, TG: Triglycerides, LDL-c: Low-Density Lipoprotein Cholesterol, HDL-c: High-Density Lipoprotein Cholesterol: P-value determined using Chi-square test

Magnitude of dyslipidemia according to comorbidity and lifestyle practices of participants

Regarding the respondents’ lifestyle, 287(74.7%) and 311(81.0%) reported that they did not regularly eat fruits/vegetables. While 139 people (36.2%) and 34 (8.9%) had experienced overweight and obesity, respectively, half of the hypertensive individuals (51.6%) had maintained normal body weight. Additionally, 319 hypertensive patients (83.1%) reported chewing tobacco, 60 (15.6%) claimed now smoking cigarettes and 67 participants (17.4%) reported currently drinking alcohol. Only 239 (62.2%) of the individuals consistently took their antihypertensive medications.

Interestingly, among those hypertensive patients who engaged in sedentary physical activity, the prevalence of atherogenic dyslipidemia was highest for TC, TG, LDL-c, and HDL-c at 54.0%, 57.9%, 52.1%, and 66.9%, respectively (P<0.05). Additionally, the prevalence of atherogenic dyslipidemia varied from 76.5% to 91.2%, among people who were overweight or obese, while it ranged from 26.3 to 51.0% in those with normal body weight (p <0.005). Furthermore, a raised waist circumference, long-term hypertension, and familial history of hypercholesterolemia were all consistently associated with low HDL-c (p <0.005). Similarly, among those who reported a familial history of hypercholesterolemia, TC, TG, LDL-c, and HDL-c lipid derangements were prevalent in 80.8%, 74.4%, 69.2%, and 84.6% of cases, respectively. Patients with DM co-morbidities had the highest prevalence of elevated LDL-c (72.4%) with a P-value<0.005). Additionally, as shown in the table below, atherogenic dyslipidemia varied from 66.0% for LDL-c to 76.7% for HDL-cholesterol (P<0.05) among people with hypertension for at least 10 years (Table 2).

Table 2. Distribution of dyslipidemia by behavioural and lifestyle characteristics and other medical profiles of hypertensive patients in Northeast Ethiopia, 2021 (n = 384).

Variables Frequency (%) TC ≥ 200 mg/dL N (%) TG ≥ 150 mg/dL N (%) LDL-c > 130 mg/dL N (%) HDL-c < 40 mg/dL N (%)
Regular physical activity Yes 73(19.0) 15(20.5) 13(17.8) 8(10.9) 21(28.8)
No 311(81.0) 168(54.0) 180(57.9) 162(52.1) 208(66.9)
P-value 0.01 <0.001 0.003 0.04
Eating habits of fruits/vegetables Yes 97(25.3) 30(30.9) 29(29.9) 16(16.5) 24(24.7)
No 287(74.7) 153(53.3) 164(57.1) 154(53.6) 205(71.4)
P-value 0.007 0.03 0.02 0.06
Body mass index Underweight 13(3.4) 5(38.5) 7(53.8) 4(30.8) 5(38.5)
Normal 198(51.6) 55(27.8) 66(33.3) 52(26.3) 101(51.0)
Overweight 139(36.2) 93(66.9) 89(64.0) 86(61.8) 102(73.4)
Obesity 34(8.9) 30(88.2) 31(91.2) 28(82.4) 26(76.5)
P-value 0.001 <0.001 0.004 0.003
Waist circumference (cm) (Men/women) < 94/80 243(63.3) 100(41.2) 109(44.8) 95(39.1) 139(57.2)
≥94/80 141(36.7) 103(73.0) 94(66.7) 105(74.5) 110(78.0)
P-value 0.003 <0.001 0.01 0.002
Current alcohol consumption No 317(82.6) 147(46.4) 156(49.2) 136(42.9) 190(60.0)
Yes 67(17.4) 36(53.7) 37(55.2) 34(50.7) 39(58.2)
P-value 0.07 0.36 0.29 0.29
Current cigarettes smoking No 324(84.4) 157(48.4) 150(46.3) 131(40.4) 188(58.0)
Yes 60(15.6) 26(43.3) 43(71.7) 39(65.0) 41(68.3)
P-value 0.004 0.04 0.02 0.07
Habit of chat chewing No 65(16.9) 33(50.8) 34(52.3) 15(23.1) 40(61.5)
Yes 319(83.1) 169(53.0) 159(49.8) 155(48.6) 189(59.2)
P-value 0.06 0.54 0.34 0.07
Adherence to antihypertensive medicines Yes 239(62.2) 120(50.4) 80.8(33.8) 59(24.6) 84(35.2)
No 245(63.8) 163(66.5) 146(59.6) 136(55.5) 180(73.5)
P-value 0.03 0.009 0.03 0.04
Duration of hypertension in year <5 157(40.9) 32(20.4) 45(28.7) 22(14.0) 60(38.2)
5–9 77(20.0) 43(55.8) 55(71.4) 49(63.6) 54(70.1)
≥10 150(39.1) 108(72.0) 113(75.3) 99(66.0) 115(76.7)
P-value <0.001 0.01 0.01 0.007
Comorbidity with hypertension No diseases 294(76.5) 143(48.6) 150(51.0) 117(39.8) 175(59.5)
Renal 9(2.3) 5(55.5) 6(66.7) 6(66.7) 7(77.8)
Diabetes 76(19.8) 46(60.5) 47(61.8) 55(72.4) 47(61.8)
Liver 6(1.4) 3(50.0) 3(50.0) 2(33.3) 2(33.3)
P-value 0.001 0.005 0.001 0.02
Family history of hypercholestronimia No 306(79.7) 120(39.2) 135(44.1) 116(37.9) 183(59.8)
Yes 78(20.3) 63(80.8) 58(74.4) 54(69.2) 66(84.6)
P-value 0.04 0.03 0.02 0.004
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Note: TC: Total cholesterol, TG: Triglycerides, LDL-c: Low-Density Lipoprotein Cholesterol, HDL-c: High-Density Lipoprotein Cholesterol: P-value determined using Chi-square test

Female hypertensive patients had significantly higher mean serum concentrations of TC, LDL-c, HDL-c, and TG (p-value<0.05). Besides, the derived mean ±standard deviation (SD) of the TC, LDL-c, and HDL-c and the median value of TG were 198.6±54.2, 123.3±41.2, 40.2±10.4, 170±109.7 for combined sexes respectively (Table 3).

Table 3. The mean/median values of serum lipid profile and other risk factors stratified by gender (n = 384).

Variables All Women Men p-value
Age 46.5±12.7 45.5±13.0 47.6±12.3 0.1
TC 198.6±54.2 201.0±44.1 196.6±33.8 0.02
TG 170±109.7 170±89.3 135±79.7 0.04
LDL-c 123.3±41.2 125.7±23.1 121.1±32.8 0.01
HDL-c 40.2±10.4 41.1±12.1 39.1±11.4 0.01
BMI 24.4±3.8 24.2±4.0 24.6±3.6 0.02
WC (cm) 93.1±11.2 83.4±12.8 84.2±9.0 <0.001
SBP/DBP(mmHg) 146.7±17.1/86.3±13.5 147±13.8/87.2±9.7 143.8±10.5/88.4±11.7 0.44/0.06
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Note: TC: Total cholesterol, TG: Triglycerides, LDL-C: Low-Density Lipoprotein Cholesterol HDL-C: High-Density Lipoprotein Cholesterol, BMI: Body mass index, WC: Waist Circumference, DBP: diastolic blood pressure, SBP: Systolic Blood Pressure; P-value determined using Student’s t-test,

P-value determined using Mann-Whitney Test

Co-occurrence of the lipid abnormalities and raised TC/HDL-c ratio

In the study subjects, the combined elevation of TC+TG was 68 (37.4%), 50 (24.8%) for males, and 50 (24.8%) for females. Similarly, the overall prevalence of elevated TC+LDL-c was 76 (37.6 percent) for males and 73 (40.1%) for female hypertensive patients. Besides, the prevalence of three lipid profile derangements (TC+TG+LDL-c) in a single individual was 89 (23.2%), while 67 (17.4%) of the hypertensive subjects had exhibited abnormalities in all four serum lipids. The present study revealed that the majority (93.2%; 95%CI: 90.6–95.6) of the hypertensive patients had experienced dyslipidemia in at least one lipid profile that is compatible with the diagnosis of dyslipidemia. Moreover, this work noted that more than half (52.3%) of the hypertensive patients had a raised TC/HDL-c ratio (Table 4).

Table 4. Co-occurrence of the four lipid derangements among hypertensive patients stratified by gender in Northeast Ethiopia, 2021.

Combined lipid derangements Female (n = 182) Male (n = 202) Combined sexes (n = 384)
Yes N (%) No N (%) Yes N (%) No N (%) Yes N (%) No N (%)
TC+TG elevated 68 (37.4) 114 (62.6) 50 (24.8) 152 (75.2) 118 (30.7) 266 (69.3)
TC+LDL-c elevated 73 (40.1) 109 (59.9) 76 (37.6) 126 (62.4) 149 (38.8) 235 (61.2)
Elevated TC +reduced HDL-c 67 (36.8) 115 (63.2) 62 (30.7) 140 (69.3) 129 (33.6) 255 (66.4)
TC+TG+LDL-c elevated 49 (26.9) 133 (73.1) 40 (19.8) 162 (80.2) 89 (23.2) 295 (76.8)
TC+TG+LDL-c+HDL-c 37 (20.3) 145 (79.7) 30 (14.9) 172 (85.1) 67 (17.4) 317 (82.6)
Overall prevalence of dyslipidemia in at least one lipid profile 167 (91.8) 15 (8.2) 191 (94.6) 11 (5.4) 358 (93.2) 26 (6.8)
TC/HDL-c ratio ≥5 111 (61.0) 71 (39.0) 90 (44.6) 112 (55.4) 201 (52.3) 183 (47.7)
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Abbreviations: TC: Total cholesterol, TG: Triglycerides, LDL-c: Low-Density Lipoprotein Cholesterol, HDL-c: High-Density Lipoprotein Cholesterol

Predictors of dyslipidemia among hypertensive patients

In the bivariate analysis model, many predictors such as sex, age, marital status, occupation, taking antihypertensive medicine, duration of hypertension, family history of hypercholesterolemia, BMI, current cigarette smoking, and comorbidity were recruited as risk factors for most of the lipid profile derangements (P-value<0.05). Participants whose age ≥ 40 years were at higher risk for having elevated levels of TC and TG with a value of (AOR: 3.22, 95% CI: 2.40–4.32, P-value<0.001), and (AOR: 2.30, 95% CI: 1.21–3.79, P-value = 0.04) than those who were below 40 years of age respectively. Regarding sex, female hypertensive individuals are at higher risk for having elevated concentrations of TC (AOR: 2.02, 95% CI: 1.26–3.70, P-value = 0.02), and TG (AOR: 1.52, 95% CI: 1.02–1.92, P-value = 0.005) than male counterparts. Moreover, participants who had sedentary lifestyles are at more risk for having elevated atherogenic TC and TG levels (AOR: 2.01, 95% CI: 1.52–2.89, P-value = 0.03), and TG (AOR: 1.94, 95% CI: 1.25–2.69, P-value = 0.04), respectively. Additionally, obese people are more likely to have high concentrations of TC (AOR: 2.57, 95%CI: 1.97–3.22, P-value = 0.01) and TG (AOR: 2.23, 95%CI: 1.29–4.16, P-value = 0.03). Likewise, multivariate analysis revealed that current cigarette smoking and the habit of not eating fruits and vegetables were significantly associated with elevated TC levels but not with elevated TG levels (Table 5).

Table 5. Multivariable logistic regression analysis of factors associated with elevated serum total cholesterol and triglycerides levels among hypertensive patients in Northeast Ethiopia, 2021 (n = 384).

Variables TC ≥ 200 mg/dL TG ≥ 150 mg/dL
COR (95%CI) P-value AOR (95%CI) p-value COR (95%CI) P-value AOR (95%CI) P-value
Age in year 18–39 1 <0.001 1 <0.001 1 0.01 1 0.04
1.57(1.06–1.89) 2.30(1.21–3.79)
≥40 2.09(1.16–3.70) 3.22(2.240–4.32)
Sex Male 1 0.03 1 0.02 1 0.001 1 0.005
Female 1.25(0.84–1.86) 2.02(1.26–3.70) 2.01(1.34–3.02) 1.52(1.02–1.92)
Residence Rural 1 0.006 1 0.03 1 0.002 1 0.006
Urban- 1.92(1.02–2.53) 1.68(1.03–2.36) 1.28(0.86–1.92) 2.06(1.56–3.72)
Marital status Single 1 0.03 1 0.30 1 0.04 1 0.56 0.63 0.21
Married 0.36(0.15–0.89) 0.66( 1.38(1.15–1.96) 0.97(0.57–1.66)
Divorced 0.86(0.38–2.00) 0.86(0.66–1.14)
Widowed 1.08(0.40–2.90) 1.50(1.21–2.10) 0.97(0.44–2.11)
1.45(1.16–2.25) 1.78(0.65–4.88)
Occupations Government employee and Student Nongovernment 1 0.01 1 0.51 1 0.04 1 0.07 0.04 0.03
1.43(0.24–0.75) 1.11(0.56–2.18) 1.04(0.60–1.81) 1.58(0.79–3.17)
1.52(0.27–1.00) 1.21(0.55–2.69)
1.67(0.38–1.20) 1.95(1.08–3.11) 1.22(0.72–1.08) 1.21(0.68–2.16)
Self employed Farmer
1.48(0.80–2.75) 1.75(1.40–2.42)
Monthly income in ETB/month >3000 1 0.90 1 0.66
2001–3000 0.97(0.54–1.71) 1.22(0.72–2.08)
1000–2000 1.03(0.57–1.87)
<1000 1.20(0.64–2.21) 1.33(0.67–2.31)
0.97(0.55–1.72)
Educational status Secondary and above 1 0.27 1 0.65
0.75(0.43–1.32) 0.81(0.25–1.46)
Primary 0.70(0.45–1.10)
0.77(0.24–1.35)
Illiterate
Regular physical activity Yes 1 0.04 1 0.03 1 0.01 1 0.04
No 2.15(1.57–2.98) 2.01(1.25–2.89) 1.70(1.42–2.16) 1.94(1.52–2.69)
Eating habits of fruits/vegetables Yes 1 0.03 1 0.02 1 0.77
No 1.30(0.82–2.07) 2.31(1.36–3.12) 0.93(0.59–1.48)
Body mass index Underweight 1 <0.001 1 0.01 1 0.02 1 0.52 0.04 0.03
Normal 0.26(0.07–1.00) 1.33(0.88–1.40) 0.74(0.24–2.29) 0.42(0.12–1.44)
1.70(1.07–2.93)
1.03(0.33–2.23) 1.60(0.91–2.07)
Overweight 1.27(0.82–1.58) 2.57(1.97–3.22)
1.96(1.17–3.47) 2.23(1.29–4.16)
Obesity 1.52(0.93–2.16)
Waist circumference (cm) (Men/women) < 94/80 1 0.001 1 0.007 1 0.006 1 <0.001
3.20(1.88–5.45)
≥94/80 2.05(1.14–3.12) 2.17(1.23–3.83) 1.81(1.09–2.76)
Habit of drinking alcohol No 1 0.27 1 0.37
Yes 0.74(0.14–1.26) 1.27(0.75–2.16)
Current cigarettes smoking No 1 0.04 1 0.04 1 0.03 1 0.09
Yes 1.79(1.14–2.41) 1.49(1.14–2.87) 1.96(1.55–2.65) 1.84(1.45–2.57)
Habit of chat chewing No 1 0.58 1 0.04 1 0.56
Yes 1.16(0.68–1.98) 1.91(1.53–2.54) 1.20(0.66–2.17)
Adherence to antihypertensive medicines Yes 1 0.02 1 0.03 1 0.05 1 0.03
No 2.19(1.18–2.89) 2.18(1.68–2.83) 1.88(1.58–2.33) 2.32(1.79–2.92)
Duration of hypertension in year <5 1 <0.001 1 0.009 1 0.01 1 0.04
5–9 1.49(1.17–1.97) 1.60(0.71–3.60) 1.57(1.16–1.90) 1.53(0.73–3.21)
≥10 2.57(1.78–3.13) 3.11(1.43–6.77)
2.13(1.65–2.98) 2.80(1.28–4.95)
Comorbidity with hypertension No diseases 1 <0.001 1 0.01 1 0.03 1 0.02 0.008 0.07
1.59(1.31–2.12) 1.75(1.15–2.25) 1.60(1.19–8.70)
Renal 2.15(1.56–4.76) 2.86(1.65–3.14)
Diabetes 2.83(2.11–6.11) 1.02(0.53–2.11) 2.56(1.67–9.84) 3.29(1.80–4.42)
Liver 1.78(1.15–4.13)
1.96(1.19–4.83) 1.28(0.60–2.75)
Family history of hypercholestronimia No 1 0.05 1 0.02 1 0.04 1 0.04
Yes 1.63(1.11–3.01) 1.65(1.13–2.59) 1.84(1.21–2.37) 2.18(1.29–3.02)
Open in a new tab

Abbreviation: TC: Total cholesterol, TG: Triglycerides, LDL-c: Low-Density Lipoprotein Cholesterol, HDL-c: High-Density Lipoprotein Cholesterol: COR: crude Odds Ratio; AOR: adjusted Odds Ratio, CI: Confidence interval

The odds of aberrant LDL-c and HDL-c were also 4.68 (AOR: 4.68, 95%CI: 2.0–10.95) and 1.22 (AOR: 1.22, 95%CI: 0.58–2.56) times higher among patients aged 40 years and older, respectively, compared to subjects aged below 40 years, in the multivariable logistic regression model. Participants with a history of current smoking had 1.75 (AOR: 1.75, 95%CI: 1.19–2.43) and 1.8 (AOR: 1.81, 1.41–1.60) times the odds of developing LDL-c and HDL-c than non-smokers, respectively. Those with increased waist circumference were more likely than those with normal waist circumference to have aberrant LDL-c and HDL-c levels (AOR: 1.64, 95%CI: 0.95–2.83) and (AOR: 2.21, 95%CI: 1.28–3.89), respectively. Besides, sedentary lifestyles were associated with 2.5 (AOR: 2.48, 95%CI: 1.18–3.79) and 2.2 (AOR: 2.24, 95%CI: 1.24–4.04) times greater risks of atherogenic LDL-c and HDL-c abnormalities, respectively. Hypertensive patients with DM comorbidity were more likely than those without to have abnormal LDL-c and HDL-c levels by 2.58 (AOR: 2.58, 95%CI: 1.59–4.21) and 2.2 (AOR: 2.20, 95%CI: 1.25–3.74) times, respectively. In addition, those who reported having a family history of hypercholesterolemia had a 1.49 (AOR: 1.49, 95%CI: 1.07–1.91) and 1.90 (AOR: 1.90, 95%CI: 1.31–2.52) times higher risk of LDL-c and HDL-c abnormalities, respectively, compared to those who did not report a family history of hypercholesterolemia (Table 6).

Table 6. Multivariable logistic regression analysis of factors associated with elevated serum LDL-c and reduced HDL-c levels among hypertensive patients in Northeast, Ethiopia, 2021 (n = 384).

Variables LDL-c > 130 mg/dL HDL-c <40 mg/dL
COR (95%CI) P-value AOR (95%CI) P-value COR (95%CI) P-value AOR (95%CI) P-value
Age in year 18–40 1 <0.001 1 <0.001 1 0.02 1 0.59
>40 6.71(3.95–11.39) 4.68(2.0–10.95) 1.67(1.09–2.58) 1.22(0.58–2.56)
Sex Male 1 0.02 0.71(0.42–1.19) 0.19 1 0.03 1 0.014
Female 1.76(0.51–2.14) 1.63(1.02–1.96) 1.55(0.54–2.89)
Residence Rural 1 0.03 1 0.01 1 0.21 1 0.25
Urban 2.80(1.91–3.65) 2.01(1.45–3.43) 0.77(0.11–1.26) 0.77(0.19–1.20)
Marital status Single 1 0.03 1 0.84 1 0.023 1 0.39 0.35 0.21
Married 1.80(1.1–2.96) 0.87(0.47–1.61) 1.49(0.92–2.41) 1.31(0.77–2.22)
Divorced 2.58(1.25–5.29) 1.12(0.52–2.45)
Widowed 2.23(0.91–5.42) 1.06(0.45–2.50) 1.24(0.61–2.52) 2.00(0.71–3.61)
0.67(0.24–1.86) 2.33(0.90–4.06)
Occupations Government employee and Student 1 0.002 1 0.031 1 0.38
1.54(0.81–2.92) 0.82(0.44–1.53)
1.37(0.72–2.59)
1.96(1.14–3.40) 1.45(0.74–2.17) 0.84(0.24–2.54)
3.04(1.71–5.39)
Nongovernment 1.70(0.32–2.85) 1.47(0.84–2.92
Self employed
Farmer
Monthly income in ETB >3000 1 0.38 1 0.89
2001–3000 0.97(0.57–1.65) 1.24(0.72–2.14)
1000–2000 0.78(0.45–1.38)
1.08(0.62–1.90)
<1000 1.36(0.77–2.41)
1.10(0.32–1.97)
Educational status Secondary and above 1 0.04 1 0.07 1 0.72
1.25(0.69–2.26)
0.77(0.38–1.58)
0.75(0.41–1.36) 1.24(0.71–2.19)
0.90(0.46–1.75)
Primary 1.33(0.76–2.33)
Illiterate
Regular physical activity Yes 1 0.002 1 0.02 1 0.014 1 0.008
2.48(1.18–3.79) 2.47(1.88–2.45) 2.24(1.24–4.04)
No 2.35(1.80–3.28)
Eating habits of fruits/vegetables Yes 1 0.031 1 0.04 1 0.034 1 0.04
No 2.12(1.17–3.78) 2.33(1.76–3.30) 1.24(0.78–2.01) 1.40(.83–2.30)
Body mass index Underweight 1 <0.001 1 0.001 1 0.014 1 0.31 0.03 0.02
Normal 1.12(0.33–3.79) 0.55(0.13–2.31) 1.13(0.27–2.77) 1.65(1.19–2.92)
Overweight 2.71(0.80–9.23) 1.90(1.14–3.66)
Obesity 3.40(1.34–5.68) 1.36(0.33–5.71) 2.03(1.24–4.48) 2.71(1.77–4.58)
2.1(1.41–7.83) 3.13(1.97–5.10)
Waist circumference (cm) (Men/women) < 94/80 1 0.008 1 0.009 1 0.002 1 0.004
≥94/80 1.77(1.16–2.69) 1.64(0.95–2.83) 2.32(1.86–3.02) 2.21(1.28–3.89)
Current alcohol consumption No 1 0.12 1 0.45 1 0.79
Yes 0.65(0.18–1.13) 0.92(0.52–1.65) 0.93(0.55–1.59)
Current cigarette smoking No 1 0.042 1 0.05 1 0.025 1 0.03
Yes 1.96(1.21–2.62) 1.81(1.14–3.60) 2.00(1.38–2.29) 1.75(1.19–2.43)
Habit of chat chewing No 1 0.03 1 0.041 1 0.73
Yes 2.33(1.77–3.30) 1.25(0.65–2.41) 0.91(0.53–1.57)
Adherence to antihypertensive medicines Yes 1 0.021 1 0.042 1 0.001 1 0.02
No 1.90(1.58–2.36) 1.04(0.64–1.70) 2.33(1.87–3.05) 1.76(1.08–2.20)
Duration of hypertension in year <5 1 <0.001 1 0.03 1 0.04 1 0.02 0.01
1.06(0.50–2.26)
5–10 4.32(2.42–7.74) 1.43(0.63–3.23) 1.41(0.90–2.23) 1.63(0.72–3.66)
≥10 4.73(2.89–7.74)
2.10(1.17–3.74)
Comorbidity with hypertension No diseases 1 0.02 1 0.043 1 0.001 1 0.04 0.03 0.34
Renal 1.21(0.72–2.02) 1.96(1.21–2.80) 1.03(0.61–1.74) 1.02(0.56–1.78)
Diabetes 1.58(0.47–5.29) 2.20(1.25–3.74)
Liver 0.66(0.12–3.64) 2.58(1.59–4.21) 2.81(1.47–4.98) 0.40(0.07–1.32)
1.63(1.09–2.24) 1.34(0.66–2.89)
Family history of hypercholestronimia No 1 0.016 1 0.023 1 0.001 1 0.007
Yes 1.54(0.33–1.89) 1.49(1.07–2.91) 2.49(1.69–3.60) 1.90(1.13–2.52)
Open in a new tab

Abbreviation: TC: Total cholesterol, TG: Triglycerides, LDL-c: Low-Density Lipoprotein Cholesterol, HDL-c: High-Density Lipoprotein Cholesterol: COR: crude Odds Ratio; AOR: adjusted Odds Ratio, CI: Confidence interval

Discussion

Dyslipidemia was made worse by hypertension’s impact on the blood lipid metabolism. Blood lipid concentrations and blood pressure were linked to and impacted by each other, and atherogenic dyslipidemia increased blood pressure variability. In emerging nations, atherogenic dyslipidemia, which is becoming more prevalent, is a significant risk factor for CVD emergence [9, 10]. Majority (93.2%) of the hypertensive patients in this study had at least one lipid profile with atherogenic dyslipidemia, and 17.4% to 38.8% had dyslipidemia with two or more lipid profile derangements. In line with the present study a high prevalence dyslipidemia were reported in Southern part of Ethiopia (90.8%) [28], Lithuania (89.7%) [35], South Africa (85.0%) [36], Poland (77.2%) [37] and Indonesia (79.5%) [38]. However, this finding is higher than previous studies done in Gojjam Ethiopia (48.4%) [27], Mekelle Ethiopia (66.7%) [39], Harar Ethiopia (34.8%) [40], South Africa (67.3%) [41], Uganda (63.3%) [42], Palestine (66.4%) [43] and Iran (30.0%) [44]. In the current study, we recruited only hypertensive patients who were at higher risk for dyslipidemia than general populations. Moreover, this difference might be due to variation in the lifestyles and behavioral characteristics of respondents, sample size, method, stage of urbanization, cut-off values, and socioeconomic status.

Abnormally reduced HDL-c was the most prevalent (59.6%) component of dyslipidemia followed by elevated TG levels (50.3%), which is in line with previous studies [27, 28, 45–48]. Low HDL-c has been linked to atherogenesis and the development of cardiovascular disease, according to data. Most of the patients in our study were at high risk of developing CVD. Besides, the prevalence of elevated LDL-c was 44.3%, which was consistent with earlier studies done in Mekelle, Ethiopia (49.5%) [39], India (47.8%) [49], Iran (50.0%) [50], Thailand (56.5%) [51], Uganda (60.9%) [52], Ghana (61.0%) [53], Senegal (66.3%) [54] and Jordan (74.9%) [55]. The current finding, however, was greater than earlier studies with a similar focus that were conducted in Gojjam (16.1%) [27], and in other regions of Ethiopia (14.1%) [56], and lower than the finding from Southern Ethiopia (60.9%) [28]. The differences in the cutoffs, methodology, respondents’ lifestyle, behavioral patterns, and the socioeconomic position may be to blame for these disparities in the results.

The prevalence of elevated total cholesterol (47.7%) is comparable to studies conducted in other African nations [52–54, 56, 57], but greater than those conducted in Harar Ethiopia (33.7%) [40], Southern Ethiopia (38.7%) [28], Mekelle (30.8%) [39], Gojjam (19.6%) [27], and Iran (29.6%) [44]. Interestingly, the prevalence of raised triglycerides (50.3%) in this study was higher than the results from Cameroon (18.9%) [58], Nigeria (9.9%] [59], Ethiopia (21.0%) [56], Malawi (28.7%) [60], Venezuela (39.7%) [61], Jordan (41.9%) [55], and Uganda (42.1%) [52]. This report, however, was lower than the result in Southern Ethiopia (62.2%) [28] but in line with findings reported in Thailand (49.9%) [51], India (56.1%) [49], South Africa (59.3%) [41], and Brazil (65.3%) [62]. Different study populations, methodology, ethnicity, lifestyle, length of hypertension, experiences with antihypertensive medications, and socioeconomic position could all contribute to variations in dyslipidemia prevalence.

Moreover, study discovered that the TC/HDL-C ratio is a strong marker for coronary heart disease. The risk of CVD has been heavily associated with a high TC/HDL-C ratio [63]. Thus, the current investigation found that a higher TC/HDL-c ratio was present in more than half (52.3%) of the study subjects. A study conducted in Karnataka revealed almost similar result (50.0%) [64], while Southern Ethiopia reported a lower result (36.1%) [28]. The difference may be caused by the varying research participant number, the presence of certain illnesses, the amount of dietary consumed, and the utilized cut-off values.

Significant relationships between dyslipidemia and the participant’s older age, gender, higher BMI, raised waist circumference, lack of fruit and vegetable consumption, sedentary lifestyle, comorbidity, long-term hypertension for more than five years, non-adherence to antihypertensive medications, and current smoking were also found. Dyslipidemia was seen in between 55.0 and 64.0% of people below the age of 40. This is higher than a previous Ethiopian study that revealed 18.7 to 32.5% [27] but lower than research results reported in other publications [65–71]. This increased frequency may be explained by the fact that middle-aged and older people were more vulnerable to the effects of many chronic diseases as physical function declined with age.

Additionally, this study found a positive correlation between elevated waist circumference and dyslipidemia, which is similar with the results of other earlier investigations [72–77]. Derangements in lipid profiles were present in 66.7 to 78.0%. Besides, respondents who were not engaged in regular physical activities experienced serum lipid abnormalities ranging from 52.1% to 66.9%. Similar findings were found in an earlier Ethiopian study that found lipid abnormalities in people who lead sedentary lifestyles to range from 26.4 to 64.4% [28]. Additionally, the prevalence of lipid change among obese, hypertensive people ranged from 76.5% to 91.2%, which is higher than the 32.3% to 56.9% seen in a previous Ethiopian study [27]. Dyslipidemia can develop in people who have sedentary lives, have high BMIs, and have large waist circumferences. Individuals with, sedentary lifestyles, raised BMI, and waist circumference might accumulate excessive fat, which leads to dyslipidemia. Besides, the variation among studies might be due to differences in the study population, methodology, age composition.

The results of the current investigation showed that sex and dyslipidemia were significantly linked. In line with this study, a number of earlier investigations found that the prevalence of dyslipidemia was much greater in women [27, 28, 78, 79]. On the other hand, a prior study found that men had a higher risk of dyslipidemia [80]. Additionally, respondents who had long-term hypertension (66.0 to 76.7%), a family history of hypercholesterolemia (69.2 to 84.6%), and diabetes co-morbidity (60.5 to 72.4%) showed atherogenic dyslipidemia. Dyslipidemia was also strongly linked to non-adherence to antihypertensive medications (55.5 to 73.5%) and infrequent consumption of fruits and vegetables (53.3 to 71.4%). A prior study in Harar, Ethiopia, revealed comparable results regarding consumption of fewer fruits and vegetables [40]. The prevalence of dyslipidemia was substantially correlated with current cigarette smoking, though, with a range of 43.3 to 71.7%, which is consistent with the results of other studies conducted in Saudi Arabia [71].

There were several restrictions placed on the study. The capacity to address causal links between dyslipidemia and its recognized risk variables among hypertension patients is constrained by all cross-sectional study methods, to start with. Second, since the information was gathered by a questionnaire, there could be a bias toward memory.

Conclusion

It can be concluded from this study that hypertensive patients frequently have atherogenic dyslipidemia, particularly low HDL-c and high triglyceride levels. Besides, the study indicated that age, gender, residence, BMI, the habit of eating fruits/vegetables, current smoking, regular physical activity, duration of hypertension, adhering to antihypertensive medicines, family history of hypercholesterolemia, and comorbidity were predictors of dyslipidemia. Therefore, it is crucial to perform suitable intervention programs aiming at risk factor reduction and establish regular screening programs for blood lipid concentrations in order to combat atherogenic dyslipidemia and the potential development of CVD. We suggest health education programs on behavioral and lifestyle changes for improving the health of hypertension patients based on the findings.

Supporting information

S1 Data

(SAV)

Click here for additional data file. (31.7KB, sav)

Acknowledgments

The authors would like to thank all study participants, data collectors, and all health institutions for their support.

Data Availability

All relevant data are within the paper and its Supporting information files.

Funding Statement

The authors received no specific funding for this work.

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Decision Letter 0

Paolo Magni

9 Aug 2022

PONE-D-22-18116Atherogenic dyslipidemia and associated risk factors among hypertensive patients of five health facilities in Northeast EthiopiaPLOS ONE

Dear Dr. Ousman Mohammed,

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Additional Editor Comments:

The paper requires some polishing of the language and some details still need to be improved according to Reviewer 2.

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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?

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Reviewer #1: Yes

Reviewer #2: No

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

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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: A well written report of an interesting topic in Ethiopia. The manuscript is technically sound and all the data support the conclusions. The statistical analysis has been performed appropriately and rigorously. Well done.

Reviewer #2: This manuscript answers a relevant research question and uses the correct methodology to do so.

While it should be clear that associations found through the logistic regression are exploratory in nature, with the study not powered to consider this amount of predictors, the level of proof is generally high.

The manuscript is of decent quality and almost ready for publication as far as I am concerned, although some improvements and clean-up remains to be done.

Please find my suggestions for updates below.

Major comments

(1) The primary objective and most important outcome of this study is the percentage of hypertensive people with dyslipidemia. The sample size was calculated to estimate this with a specific precision.

Yet, no confidence intervals are presented around the point estimates of the actual percentage of hypertensive people with dyslipidemia. Such CIs are useful as they indeed show how precise the estimates for prevalence of the different dyslipidemia markers are.

(2) Wording referring to the population (results, discussion):

Sometimes “participants” is used, other times “people” or identifiers like “women”.

None of these are technically correct. The population here is “people with hypertension in Northeast Ethiopia”, which is different from the sample (a subset of such people) or from “people” in general.

While it doesn’t need to be repeated constantly, some attention should be given throughout the manuscript to the fact that this analysis is representative for the proper population: people with hypertension in Northeast Ethiopia.

This is correctly done in the abstract and conclusion.

(3) Material & Methods: sometimes too much details are given and information tends to get needlessly repeated

Examples: definition of BMI (repeated twice, and common knowledge so not needed), multiple repeats on how height measurements are taken, paragraph on quality control can probably be shortened, …

(4) Table 5: please format the table better, it is hard to read like this.

Table 5 and Table 6: please doublecheck all numbers carefully. Some results, while possible, are a bit strange.

It is unclear to me how confidence intervals for logistic regression are calculated in SPSS, these results do not match what other statistical software could give.

A few examples: 2.02(1.62-3.70) (maybe the lower bound is 1.26?); 1.33(1.08-1.40) , 2.86(1.65-3.14) (does not make sense that the estimate is closer to the upper bound in these cases).

Since it’s very easy to introduce typos when copying the results from the statistical package to the manuscript, authors should carefully doublecheck every number.

(5) Conclusion: “were significant determinants of dyslipidemia”

Alas, you did it perfect during the whole paper, even correctly explicitly mentioning that a cross-sectional study cannot address causal links.

Since no causality can be concluded, you should not state that these are “determinants” of dyslipidemia. Instead using “predictors” or “significantly associated” are both correct options.

(6) I did not find a data sharing statement in the manuscript. Instead, when talking about data sharing, you replied "No - some restrictions will apply" and data available "On request". I understand that this is not a sufficiently detailed answer in light of the PLOS Data Policy. Please provide clear instructions on how a sufficiently anonymised version of the data can be obtained.

Minor comments:

(7) Abstract and page 7 (Data analysis):

“Statistical significance was declared at p ≤0.05.”

Please change to p < 0.05 (shouldn’t make a difference in results or interpretation).

(8) Page 5: (Study Population and legibility Criteria)

“All volunteer hypertensive patients (…) were eligible. However (…)”

Please rewrite. The part following “however” makes it clear that not all patients were eligible.

(9) Page 5: (Data collection and quality control)

“Well-trained two data collectors”

Rewrite to “Two well-trained data collectors”

(10) Table 1:

HDL-c <40 mg/dL vs. occupation: p-value is missing for this specific comparison

(11) Page 11, bottom:

“the habit of not eating fruits and vegetables were substantially linked with elevated TC levels but not with elevated TG levels (Table 5).”

Replace substantially by significantly. Substantial would be linked to effect size, while this statement should only refer only to statistical significance.

(12) Page 14:

“(AOR: 1.49, 95%CI: 127-1.91)”: add decimal sign in 1.27

“and 2.0 (AOR: 1.90, 95%CI: 1.51-2.52)”: change 2.0 by 1.9

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Reviewer #1: No

Reviewer #2: No

**********

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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.

PLoS One. 2023 Feb 14;18(2):e0277185. doi: 10.1371/journal.pone.0277185.r002

Author response to Decision Letter 0

16 Aug 2022

Dear editors and reviewers, I greatly acknowledge your comments which are actually very crucial for the quality of the paper as well as for my future improvements. As per your comments, all things are corrected and the corrected parts were alighted with green.

Major comments

Reviewer point #1): The primary objective and most important outcome of this study is the percentage of hypertensive people with dyslipidemia. The sample size was calculated to estimate this with a specific precision. Yet, no confidence intervals are presented around the point estimates of the actual percentage of hypertensive people with dyslipidemia. Such CIs are useful as they indeed show how precise the estimates for prevalence of the different dyslipidemia markers are.

Author response: Yes, we agreed with the reviewers, a 95% CI was calculated and indicated in the result part. Here is the calculated CI (93.2%; 95%CI: 90.6-95.6)

Reviewer point #2): Wording referring to the population (results, discussion): Sometimes “participants” is used, other times “people” or identifiers like “women”. None of these are technically correct. The population here is “people with hypertension in Northeast Ethiopia”, which is different from the sample (a subset of such people) or from “people”ingeneral. While it doesn’t need to be repeated constantly, some attention should be given throughout the manuscript to the fact that this analysis is representative for the proper population: people with hypertension in Northeast Ethiopia. This is correctly done in the abstract and conclusion.

Author response: Of course, this study was inferred to the hypertensive individuals so, as per the reviewer's comment we tried to replace some identifiers like “women, people, and participants with more appropriate descriptions like hypertensive individuals or people with hypertension.

Reviewer point #3): Material & Methods: sometimes too much details are given and information tends to get needlessly repeated Examples: definition of BMI (repeated twice, and common knowledge so not needed), multiple repeats on how height measurements are taken, paragraph on quality control can probably be shortened,

Author response: Here we accepted the reviewer's comment and it was due to clerical errors. Now we avoid repetitive descriptions and unnecessary details and it was shown in the manuscript.

Reviewer point #4): Table 5: please format the table better, it is hard to read like this. Table 5 and Table 6: please doublecheck all numbers carefully. Some results, while possible, are a bit strange. It is unclear to me how confidence intervals for logistic regression are calculated in SPSS, these results do not match what other statistical software could give. A few examples: 2.02(1.62-3.70) (maybe the lower bound is 1.26?); 1.33(1.08-1.40), 2.86(1.65-3.14) (does not make sense that the estimate is closer to the upper bound in these cases).

Author response: Based on the reviewer’s suggestion we tried to check all the numbers carefully. Since it was an error while copying numbers and now it was solved and corrected.

Reviewer point #5): Conclusion: “were significant determinants of dyslipidemia” Alas, you did it perfect during the whole paper, even correctly explicitly mentioning that a cross-sectional study cannot address causal links. Since no causality can be concluded, you should not state that these are “determinants” of dyslipidemia. Instead using “predictors” or “significantly associated” are both correct options.

Author response: Yes we accept the reviewer's comment and we corrected it following the reviewer's suggestion.

Reviewer point #6): I did not find a data sharing statement in the manuscript. Instead, when talking about data sharing, you replied "No - some restrictions will apply" and data available "On request". I understand that this is not a sufficiently detailed answer in light of the PLOS Data Policy. Please provide clear instructions on how a sufficiently anonymised version of the data can be obtained.

Author response: It was an error while submitting the manuscript online and I can assure you that all relevant data are included in the paper.

Minor comments:

Reviewer point #7): Abstract and page 7 (Data analysis): “Statistical significance was declared at p ≤0.05.” Please change to p < 0.05 (shouldn’t make a difference in results or interpretation).

Author response: Yes we have corrected p ≤0.05 was changed to p < 0.05

Reviewer point #8): Page 5: (Study Population and legibility Criteria) “All volunteer hypertensive patients (…) were eligible. However (…)” Please rewrite. The part following “however” makes it clear that not all patients were eligible.

Author response: Some physiological and pathological factors that could alter serum lipid profiles, such as pregnancy, taking lipid-altering drugs, and antihyperlipidemic medications, were excluded because the study was designed to assess dyslipidemia.

Reviewer point #9): Page 5: (Data collection and quality control) “Well-trained two data collectors” Rewrite to “Two well-trained data collectors”

Author response: Yes we have to rewrite it as per the reviewer's comment.

Reviewer point #10): Table 1: HDL-c <40 mg/dL vs. occupation: p-value is missing for this specific comparison

Author response: The missing p-value was putt as 0.21 in the space provided.

Reviewer point #11): Page 11, bottom: “the habit of not eating fruits and vegetables were substantially linked with elevated TC levels but not with elevated TG levels (Table 5).”

Replace substantially by significantly. Substantial would be linked to effect size, while this statement should only refer only to statistical significance.

Author response: Here we have replaced the word ‘substantially’ with significantly and you can see it in the manuscript.

Reviewer point #12): Page 14: “(AOR: 1.49, 95%CI: 127-1.91)”: add decimal sign in 1.27 “and 2.0 (AOR: 1.90, 95%CI: 1.51-2.52)”: change 2.0 by 1.9

Author response: Yes it was corrected.

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file. (21.6KB, docx)

Decision Letter 1

Paolo Magni

21 Sep 2022

PONE-D-22-18116R1Atherogenic dyslipidemia and associated risk factors among hypertensive patients of five health facilities in Northeast EthiopiaPLOS ONE

Dear Dr. Ousman Mohammed,

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 address the reviewers'comments.

Please submit your revised manuscript by October . 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,

Paolo Magni

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 (if provided):

Some aspects need some improvement.

[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 #2: (No Response)

********** 

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: No

********** 

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: Well done on your study.

The introduction is well written, the methods are adequately described and the discussion/conclusion is supported by the results.

Maybe it could be worthy to amend the design of the tables to increase readability.

Reviewer #2: Please review the data availability policy. https://journals.plos.org/plosone/s/data-availability

It is still unclear to me whether the data source, or an anonymised version thereof will be made freely available. The statement "Yes - all data are fully available without restriction" and the reply to the comment that "all relevant data are included in the paper" are contradictory.

"All data" would at minimum be a dataset with a single line per patient that was included in the study and a single column for each variable that was reported in this manuscript. No instructions on how or where to obtain such dataset are provided.

********** 

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

**********

[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.

PLoS One. 2023 Feb 14;18(2):e0277185. doi: 10.1371/journal.pone.0277185.r004

Author response to Decision Letter 1

22 Sep 2022

Dear Editors and Reviewers,

As per your comments, everything was revised and fixed in the last submission. However, aside from the Data Availability Statement concern expressed by Reviewer 2, I couldn't find any particular concerns that still needed to be fixed and submitted with tracked modifications. I stated that there are some restrictions in my initial proposal. Naturally, it was a mistake that was done by the correspondence author alone, who neglected to pay attention during the online submission process. However, I had highlighted it in my prior responses to reviewers when I stated, "All the essential data are within the manuscript." Therefore, I have also included the Data Availability Statement by saying ‘All the relevant data are within the manuscript’ in the manuscript.

Thank you very much for your consideration.

Your Sincerely,

Attachment

Submitted filename: Response to editors and reviewers.docx

Click here for additional data file. (14.4KB, docx)

Decision Letter 2

Paolo Magni

17 Oct 2022

PONE-D-22-18116R2Atherogenic dyslipidemia and associated risk factors among hypertensive patients of five health facilities in Northeast EthiopiaPLOS ONE

Dear Dr. Mohammed,

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.

Specifically, please address the comment by the reviewer: "The data statement refers to all data being contained in the manuscript, this is not correct.".

Please submit your revised manuscript by October 26, 2022. 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,

Paolo Magni

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:

The Authors just need to address the comment by the reviewer (The data statement refers to all data being contained in the manuscript, this is not correct.).

[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)

**********

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: Yes

**********

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

**********

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: Please refer to my previous review. The data statement refers to all data being contained in the manuscript, this is not correct. Please discuss with the editor how data will be made available and/or which restrictions will apply.

**********

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: 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.

PLoS One. 2023 Feb 14;18(2):e0277185. doi: 10.1371/journal.pone.0277185.r006

Author response to Decision Letter 2

17 Oct 2022

Dear Editors and Reviewers,

Reviewer point: Have the authors made all data underlying the findings in their manuscript fully available?

Author response: Pardon me for the inconvenience. As per your comments, everything was revised and fixed in the last submission. However, I stated that there are some restrictions in my initial submission; naturally, it was a mistake that was done by the correspondence author alone, who neglected to pay attention during the online submission process. Now I assure you again there is no restriction regarding data availability at all. Therefore, I have also included the Data Availability Statement by saying; we will provide repository information for our data at acceptance as Supporting Information files. And I highlighted it with yellowish.

Editor point: 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.

Author response: I have already checked all the references, and it is complete and correct.

Thank you very much for your consideration.

Kind regards,

Ousman

Attachment

Submitted filename: Response to editors and reviewers.docx

Click here for additional data file. (15.2KB, docx)

Decision Letter 3

Paolo Magni

24 Oct 2022

Atherogenic dyslipidemia and associated risk factors among hypertensive patients of five health facilities in Northeast Ethiopia

PONE-D-22-18116R3

Dear Dr. Mohammed,

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,

Paolo Magni

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

All comments have been addressed.

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: 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 #2: Yes

**********

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: 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 #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: (No Response)

**********

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: No

**********

Acceptance letter

Paolo Magni

11 Nov 2022

PONE-D-22-18116R3

Atherogenic dyslipidemia and associated risk factors among hypertensive patients of five health facilities in Northeast Ethiopia 

Dear Dr. Mohammed:

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

Prof. Paolo Magni

Academic Editor

PLOS ONE

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    Data Availability Statement

    All relevant data are within the paper and its Supporting information files.

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