Title: Reproductive factors and risk of cardiovascular diseases and all-cause and cardiovascular
mortality in American women: NHANES 2003-2018
Version: 2 Date: 18 Nov 2023
Reviewer's report:
The study aimed to examine reproductive factors and risk of cardiovascular diseases and all-
cause and cardiovascular mortality in American women. The results are interesting. However,
I have raised some major and minor comments that would improve the manuscript.
Major comments:
1. The paper does not provide a clear justification for choosing the National Health and
Nutrition Examination Survey (NHANES) dataset as the primary data source. The limitations
and potential biases associated with NHANES data, such as self-reported information and recall
bias, are not thoroughly discussed.
2. While the study adjusts for several demographic and lifestyle factors, there is no
detailed discussion on potential confounders related to reproductive health, such as use of
hormonal contraceptives, hormone replacement therapy, or breastfeeding. These factors could
significantly impact the association between reproductive factors and cardiovascular outcomes.
3. The statistical methods used, including logistic models, COX proportional hazards models,
and restricted cubic spline models, are briefly mentioned but lack detailed explanation. The
paper should provide more information on the assumptions, limitations, and robustness of these
statistical approaches.
4. The paper claims that the results are applicable to women's health in general, but the study
population is limited to participants in the United States. The generalizability of the findings to
diverse populations and healthcare systems worldwide is not adequately addressed.
5. The paper mentions outcomes like "all-cause mortality" and "cardiovascular death," but does
not delve into the specific causes within these categories. A more detailed analysis of the specific
causes of cardiovascular events and deaths would enhance the clinical relevance of the findings.
6. The paper briefly mentions the exclusion of individuals with missing data, but the criteria for
exclusion are not explicitly stated. Understanding the completeness of the data and the reasons
for exclusion is crucial for assessing the robustness of the study.
7. The paper lacks information on sensitivity analyses performed to assess the robustness of the
findings. Sensitivity analyses considering variations in inclusion/exclusion criteria or statistical
model specifications would strengthen the study's credibility.
8. The study mentions a median follow-up of 105 months, but there is no discussion about
the temporal relationship between reproductive factors and the onset of cardiovascular events.
Understanding the time course of these relationships is essential for establishing causality.
Minor comments
1. The choice of keywords in the abstract does not fully capture the breadth of the study.
Including terms like "hormonal factors" or "women's health" could improve the discoverability
of the paper.
2. The paper uses both "cardiovascular diseases" and "CVDs" interchangeably. Maintaining
consistency in terminology throughout the paper would improve readability.
3. The paper could benefit from a more in-depth discussion of the clinical implications of the
findings. How can these results inform preventive strategies or clinical interventions for women's
cardiovascular health?
4. The literature review is limited to a few studies and lacks a comprehensive overview of
existing evidence. A more exhaustive review would strengthen the paper's contribution to the
existing knowledge.
5. The paper primarily focuses on significant associations, but the discussion could benefit from
addressing any null findings or unexpected results, providing a more balanced interpretation of
the study outcomes.
6. Expand the conclusion part.