Frank T. Spradley

Academic Editor

PLOS ONE

Revision required

PONE-D-20-38829

Social isolation but not deprivation involved in employment status after bariatric surgery.

PLOS ONE

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Régis Cohen and Marnos Fysekidis

3. We note that you state in your ethics statement in trhe manuscript text and online submission form that "We obtained written informed consent from patients during the first medical visit to have data from their medical records used in research" and "All data were fully anonymized before investigators accessed them." Please clarify how written informed consent was obtained from patients while still keeping the data anonymized before you accessed them.

Yes we confirm that the XLS table used is completely anonymized and received the agreement of our local and national ethical committee

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We indicate by NS the non-significant result in Table 2 and 3

We changed 5. We note that you state in your discussion "from an ethnic (African or North African origins) or cultural point of view, the participants might want to stay at home instead of looking for a job, and this point was not evaluated." As it is possible that a reader may construe this as reinforcing harmful stereotypes about black people, we ask that this sentence be revised. Please either:

(1) provide several citations that support the claim that African people might want to stay home instead of looking for a job,

(2) remove this sentence, or

(3) revise the sentence to state "from a cultural point of view, some participants might want to stay at home instead of looking for a job, and this point was not evaluated.

We thank you for the suggested sentence that we used in the text : “from a cultural point of view, some participants might want to stay at home instead of looking for a job, and this point was not evaluated”.

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We read it and we think we are in accordance with legal or ethical restrictions

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No

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Reviewer #1: Partly

We changed the conclusion messages at the end of discussion

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Reviewer #1: No

We added some information in presentation of table and in the text to explain the methods of statistical analysis

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Reviewer #1: No

We read and modified the text

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Reviewer #1: This study aimed to assess the impact of bariatric surgery on employment rates during a 2-year follow-up and to look at the differences between employed and unemployed participants in terms of quality of life and deprivation scores. To address the research question the authors invited 791 patients who had undergone bariatric surgery to participate, only 133 patients responded to the questionnaire, and a further 6 were excluded, leaving 127 participants (17% response rate). Between-group comparisons were conducted with ANOVA and repeated measures ANOVA and Fisher’s exact test. There was an increase in the number of employed participants 2 years after surgery. The deprivation score did not differ between employed and unemployed participants before or after surgery. Quality of life was lower for participants without a job (than those with a job) before surgery. After surgery QoL was lower for participants with a new job compared to those who retained their job.

Overall, the authors need to provide additional justification of the need for the study and what the study adds to the existing literature, particularly given the small sample size (and low response rate). In addition, the paper requires significant editing and proof-reading.

Major issues:

Abstract:

Lines 16-17: Background: This section appears to state the results of the analysis, rather than providing a rationale for the study and its overall aims. It is also unclear how the range of the increase in the employment rate has been calculated (i.e. 17-29%). These are results are not included in the body of the manuscript.

This data is extracted from Charras, L., Savall, F., Descazaux, T., Soulat, J. M., Ritz, P., & Herin, F. (2017). Comment on: systematic review and meta-analysis of occupational outcomes after bariatric surgery. Obesity surgery, 27(3), 811. We agree with reveiwer that is confusing and not a pertinent way to indicate this evidence in an abstract . We delete the information

The results presented in the Abstract are very confusing and the conclusions are not supported by the results presented.

Introduction:

Lines 52-53: References should be provided for the sentence stating that there are inconsistent results from studies looking at the occupational outcomes of bariatric surgery. This statement would benefit from an extra sentence or two summarising what these inconsistencies were. The statement then seems to be contradicted by the following sentence stating that two systematic reviews have concluded that bariatric surgery results in better employment outcomes.

We change the sentences

Lines 55-56: References should also be provided for these statements. It is unclear whether the authors are talking about past studies that have looked at the associations between QoL and deprivation and employment status in people who have had bariatric surgery or in wider population groups. These statements appear to be the main rationale for the study; however, how this study will add to the existing literature has not been well argued.

We change the sentences and add the reference

Methods:

Study design

Line 62: Further details on the study location and setting should be provided e.g. the hospital in which the study took place, the location of the hospital in France and the general characteristics of the location/region where the hospital is located (e.g. employment rate, extent of social disadvantage) and how these characteristics might differ from France as a whole.

Line 62: Could the authors please clarify what criteria defined an “eligible participant”. How many participants were excluded because they did not meet these criteria?

We change for: “From our database of patients operated of bariatric surgery we searched eligible participants in our tertiary hospital in the suburbs of Paris, France. This area is characterized by a high rate of immigration and low social economic status of its population.”

Line 67: Could the authors please clarify whether the preoperative characteristics of age, gender, weight, and BMI were collected by self-report or abstracted from medical records? Were the postoperative characteristics (particularly weight and BMI) collected in the same way, or were these collected by self-report? If these characteristics were measured in different ways before and after surgery this should be mentioned as a limitation in the Discussion.

Yes they were medically recorded before surgery and self-reported after surgery (we changed the sentences)

Line 70: Could the authors please provide (either in the text of the manuscript or in the supplementary material) the specific employment questions asked in both the pre-operative and post-operative surveys.

Yes we added a supporting material with the form sent to patients S1 Fig.

S1 Fig. Self-reporting questionnaire for employement.

What was your situation before and after the surgery (circle the correct answer)?

Before surgery

retirement

employment

Without work for more than 6 months

Unemployment

Work stoppage due to illness

After surgery

retirement

employment

Without work for more than 6 months

Unemployment

Work stoppage due to illness

Evaluation of QoL using the BAROS questionnaire

Line 89: Could the authors please clarify how they are using the BAROS questionnaire, and also why they appear to have used the original version and not the updated version (Oria HE, Moorehead MK. Updated Bariatric Analysis and Reporting Outcome System (BAROS). Surg Obes Relat Dis. 2009 Jan-Feb;5(1):60-6. doi: 10.1016/j.soard.2008.10.004. Epub 2008 Nov 1. PMID: 19161935.)?

Lines 90-94: The methods indicate that the authors have only used the quality of life component of the BAROS and not the weight-loss and change in co-morbidities components. If this is the case, can the authors provide information on why they have done this and whether it is a validated approach to only use parts of the BAROS; and how the scoring is then able to be interpreted?

We have been using the original version of this score since 2003 out of habit. We had not noticed its most recent modification. We just added the points indicated under each figure to calculate the total score and per item (as indicated in supplementary material). We indicated in the text that we used the original version and the method of calculation

Satisfaction Scale

Lines 96-98: Could the authors please clarify how patients who selected the middle points of the Satisfaction Scale (i.e. 2,3,4) were categorised in the analysis? The text gives the impression that only participants that selected responses of 0 and 5 were categorised.

Thank you for this comment we modified the sentence

Statistical analysis

Lines 100-102: The description of the statistical analysis seems to indicate that different numbers of participants have been included in the pre- and postoperative groups (four retired patients excluded from the preoperative group and five from the postoperative group). There should be the same number of patients in both groups i.e. participants who were retired either pre- or postoperatively should have been excluded from all analyses.

As indicated they were excluded of the analysis in pre or post operative analysis Lines 100-102 modified manuscript

Results

The authors should make sure in the results section that they answer the specific aims/research questions of the study.

Line 112: A response rate of 17% is extremely low (133/791 patients). This should be addressed more fully in the limitations section of the Discussion as it is possible that people who did not respond to the questionnaire were more likely to be unemployed, have higher deprivation, more comorbidities etc.

We add sentences in the limitation paragraph of discussion: “First, a poor response rate of 17 %. As noted in previous studies follow up of this population is difficult. It is not excluded that non responders were more likely to be unemployed, have higher deprivation, more comorbidities etc. We did have the means to confirm or not this hypothesis.”

Lines 152-154: More detailed information on the correlations between decrease in BMI and the social dimension of the BAROS would be useful as the authors discuss this at length in the Discussion and this is one of the key conclusions of the paper (even though it is not one of the stated aims of the study). Would these differences be considered clinically significant?

We hope to have clarified this point by new sentences : The score social life dimension of the BAROS questionnaire (item 3 of Supplementary Figure 2 BAROS questionnaire ) was positively correlated with decrease in BMI (in kg/m2) after surgery (Wilcoxon, <0.0001). The presence of “rich social connections” was associated with better weight loss.

Discussion

Lines 156-160: The summary of the results at the beginning of the Discussion do not adequately reflect the aims of the paper.

We change the first paragraph for : “In the current study, after a mean follow-up of 2.3 years after bariatric surgery, there was an improvement in employment status rate by 12% without relation with socio economic status. We identified in participants employed before surgery some significant characteristics: an initial weight inferior, a positive social life/network relationship and better physical capacity. Moreover, a good social score was associated to a better weight loss.”

Lines 161-168: The discussion about previous studies does not provide sufficient information on the similarities/differences in results with other studies or the reasons for why differences may be present.

We did some changes to improve the message

Lines 195-200: As noted above, the low response rate should be highlighted as a limitation of the study. In addition, another limitation that the authors allude to, but do not clearly state, appears to be that it is unknown whether participants were actually seeking employment during the follow-up period e.g. they note that many of the participants were women with young children. It is a major limitation if participants who were not actively looking for work were unable to be excluded from the study.

We did changes

Conclusion

Line 202: The concluding statement notes that bariatric surgery had a positive impact on improvement in related diseases. I am not clear that the study measured this association.

We changed the conclusion

Lines 203-204: Could the authors clarify what is meant by this sentence. The study did not appear to have information on whether unemployed participants were provided with opportunities to return to work. The study only found that there were no statistically significant differences in the deprivation score between employed and unemployed participants.

We clarified this point by changindg the conclusion : “Bariatric surgery had a positive impact on the professional sphere in addition to weight loss and improvement in related diseases and QoL. This return to work was independently of their socio economic status (EPICES score).. Participants with a pre-operative job had a better perception of satisfaction and BAROS scores. Moreover, social isolation was correlated with unsuccessful weight loss. »

Minor issues:

Introduction:

Lines 43-45: references should be provided for the claims made about associations between obesity and the diseases listed.

Yes we added a reference

Assessment of deprivation using EPICES

Lines 80-82: The wording of this paragraph is confusing. It reads as though the authors reduced the set of EPICES questions; however, further reading shows that this is not the case. It would be useful to provide further background on the EPICES measure of deprivation for the benefit of international readers who may not be familiar with it.

We detailed the conception of this questionnaire “The EPICES score Deprivation was assessed using the Evaluation de la Précarite´ et des Inégalites de sante´ dans les Centres d’Examens de Sante´ (Evaluation of Precarity and Inequalities in Health Examination Centers [EPICES]) score computed on the basis of individual conditions of deprivation. A first questionnaire exploring the multiple aspects of deprivation was administered to 7,208 subjects aged 16–59 years examined at 18 French Health Examinations Centers in 1999. The 42 socioeconomic questions selected from a bibliographic study on determinants of deprivation included traditional socioeconomic indicators (education, income, and occupation) and also questions related to family structure, housing conditions, employment, social benefits, financial difficulties, leisure activities, social support, childhood/adult life events, self-perceived health, and health care utilization. Data from the questionnaire were first analyzed by correspondence analysis [13]. To reduce the number of variables, multiple regression analysis was used to select a subset of indicator variables, giving a satisfactory explanation of the individual coordinate on the principal axis associated with deprivation. The regression analysis showed that 11 variables of the 42 questions explained 90% of the variance of the deprivation axis. The EPICES score is derived by summing the estimated regression coefficients corresponding to the responses to the 11 selected questions (Supplementary Figure 1). The score varied from 0 to 100, from the least deprived to the most deprived situation. The EPICES score was validated in 2002 in 200,000 subjects examined at 58 French Health Examination Centers. The EPICES score was found to be associated with health status independently of the occupational category and the French administrative definition of deprivation [14].

Results

Lines 115-117: the authors should be specific when describing the results as to whether they are referring to pre- or post-operative characteristics e.g. the mean BMI of 42.7.

We did it

Table 1

I think the third line of the table labelled “weight before surgery (kg)” is probably supposed to read “weight after surgery (kg)”.

Sorry for error corrected

It would be preferable to spell out the in full in the body of the table rather than in a footnote (there is plenty of space to do so).

We didi it

Could the authors please clarify what (N<30.17) against Score EPICES score is meant to indicate in the context of the Table?

We did it in the table

Table 2

The term “conservative job” is not a common English term. Do the authors mean Participants who were in the same job pre- and post-operatively?

You are right we do not have this information conservative job means that they are employed before and after surgery. We added this explanation in the text

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We hope to be in agreement with this. We did the analysis of our manuscript By PACE

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Submitted filename: Ethical response to reviewer.docx

Dear Editor

First of all, we thank you for the quality of the proofreading work done by your teams.

We are sorry for the shortcomings during the first proofreading and we hope to have met your expectations.

Pease find the answers to your request

ONE-D-20-38829R1

Social isolation but not deprivation involved in employment status after bariatric surgery.

PLOS ONE

Dear Dr. COHEN,

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Kind regards,

Frank T. Spradley

Academic Editor

PLOS ONE

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________________________________________

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Reviewer #1: Yes

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Reviewer #1: The authors have adequately addressed the reviewer comments; however, in addressing the request for additional information on the EPICES measure, the authors have copy and pasted paragraphs from Bihan et. al.: Association among individual deprivation, glycemic control, and diabetes complications: the EPICES score. Diabetes Care. 2005 Nov;28(11):2680-5. doi: 10.2337/diacare.28.11.2680. PMID: 16249539.

Although the authors have cited this reference, a direct copy and paste is not appropriate.

________________________________________

In this paragraph we have attempted to respond to the comments of the reviewers. For that we used a paragraph published by us and accepted describing very precisely our questionnaire. We understand the new remarks and we have changed the text while keeping the main part of the description of the EPICES questionnaire

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We accept to publish the peer review history of our manuscript. We have nothing to hide, no conflict of interest, our protocol is ethical (approved) and the data is anonymized.

Reviewer #1: No

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We did it

Kind regards,

Régis Cohen

MD, PhD

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Submitted filename: A rebuttal letter August 2021.docx