PONE-D-22-04375The Burden of Disease and Economic Impact of Sugar-Sweetened Beverages’ Consumption in Argentina: a Modeling StudyPLOS ONE

Dear Dr. Bardach,

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.

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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.

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We look forward to receiving your revised manuscript.

Kind regards,

Vijay S. Gc, PhD

Academic Editor

PLOS ONE

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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: Partly

Reviewer #2: Yes

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

Reviewer #1: I Don't Know

Reviewer #2: Yes

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: No

**********

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: This paper is a modelled study of the health and economic impact of SSB consumption in Argentina. There has clearly been much work into the development and execution of the model and the graphs and tables are great. With significant revision (minor and some major) and refinement of the use of the English language throughout, this paper has the potential to provide a good addition to the literature.

It is difficult to provide all details to such a complex modelling exercise however, a robust scientific paper is one that other research teams can obtain the same results through the same data sources, software, stakeholders, literature, reports etc. It is always useful to keep this in mind when doing scientific writing. Some specific considerations:

• Abstract:

Methods: The two last sentences should be in past tense. Please revise.

Results: It might be useful to say in the first instance of the results that ‘our model estimated that because of SSB consumption…..’.

• Introduction:

First paragraph, first sentence: needs citing.

First paragraph, last sentence: would be good to include which SDG regarded prevention and control of NCDs (i.e. SDG 3 or 3.4).

Second paragraph, first sentence, change the tense. So….’Worldwide, eight million deaths were attributed to overweight or obesity in 2019…… The sentence reads poorly. Please revise. Eg: Worldwide, eight million deaths in 2019 were attributable to overweight or obesity – two of the most critical determinants of NCD morbidity and mortality.’

Second paragraph, second sentence: what are the gender differences? This is too general. Either give values or delete. Similarly, what are some of the economic costs you speak of? Some stats would be useful for the reader.

Third paragraph, second sentence needs citing. There appears to be a lot of duplication in information in this paragraph. Suggest revising and citing correctly throughout.

Fourth paragraph: Results from studies done in the past should be written in past tense. Please revise.

Fourth, fifth and sixth paragraphs need revising. For instance, the authors begin paragraph seven by saying children and adolescents consume 40% more SSBs, confectionery and then go on to give stats for adult obesity. Would be much better to give stats at this point for child and adolescent obesity instead of talking about it in the fourth paragraph.

Seventh paragraph: You need to spell out PAHO in full the first time you use it and then use acronyms. Also, how have PAHO prioritized the need to reduce SSB consumption? It’s a very general statement and doesn’t really tell the reader anything, as it is currently is. Suggest further work.

• Methods

The authors describe in this section the two causal pathways in the model (ie. BMI and SSB consumption). However, there is no mention of how (or what) determines change in SSB consumption or how it directly effects overweight and obesity independently of BMI and this is an important and relatively new concept to understand. Some (cited) biochemical/pathological background from the global literature on this concept would be useful in the introduction to highlight just how damaging SSBs are. It would help build the argument of why the modelling is important. What determined the change in consumption? Literature? It is unclear what the difference is between the baseline and counterfactual and why that has been chosen for the model. Some explanation of this would make the results much clearer for the reader.

Figure 1 is a good figure. Describing the other diseases is useful for the reader.

First paragraph, fifth sentence needs more detail on the conceptualisation of the model. Did the authors have the policy diaglogue? Attend the dialogue? Or is the policy dialogue a report? Who hosted the dialogue? What was the dialogue on? How did these ‘activities’ help shape the model’s development? In what way? Did you follow a protocol? Did you have aims and objectives? What were the needs of the decision-makers? What policies are the ones you speak of to control SSB consumption?

For the PIFs, does it estimate the proportional reduction in incidence or prevalence of disease or mortality? The second sentence in this paragraph needs revising.

Throughout the methods section: your study was done in the past so you need to write it in the past tense (e.g., ….secondly, we estimated the effect of BMI on disease incidence…..Finally we applied….. The model calculated…

Fourth paragraph: should read ‘the estimation of the impact of SSB consumption….. please revise.

What other sensitivity analyses did you estimate? Is the STATA code available for your analyses?

The authors indicate results were generated by 1000 iterations using the distribution of SSB consumption and RRs for each country. Is the model estimating outputs for more than one country or is this an error?

• Epidemiological data

Please provide details of the data sources. What were the surveys? What were the international sources? Where did the authors obtain SSB consumption data from? What is the ‘latest nation risk factor survey’ actually called? Did the authors do any ‘fiddling’ within DISMOD? Could an independent person repeat this method and get the same results? How did you ‘identify’ the RR values? Why did you choose the diseases you did and not others?

The section could be written in a much clearer way. Suggest revising. For instance, the last sentence about the RRs from GBD (which needs to be spelt out in full the first time it’s used) should go before you begin talking about ‘identifying RRs’, the readers then know where the authors obtained the RRs from and makes it clear that is how they ‘identified’ them (if indeed it was where the values for T2DM and CVD were obtained from, it’s really not clear).

• Direct medical costs

The authors speak of macro- and micro-costing approaches but only describe the micro-costing approach. What is the macro-costing approach? Where do these concepts originate? Are they backed by theory? Previous modelling studies? Please provide more detail.

Fifth sentence: please either name the previous cost estimation projects, clinical guidelines and local experts or provide a reference for each for the reader.

• Results

Overall, the authors need to describe their findings in much more detail. It is clear they have gone to the trouble to make detailed tables, but the text descriptions to highlight the significant findings for each would improve this section a lot. Compare and contrast. For instance, the authors indicate boys were more affected than girls. By how much? How much higher was the 5-11 age group’s burden compared to the lowest? How much more affected were adults 18-44 compared to older groups? 47 million. Is that USD?

Table 1

Please provide a definition for the reader of the different grades of obesity, either in the text or in the table or as a table footnote. Different countries have different thresholds for obesity and it is important to provide explicit detail for all tables and their content. Nowhere in the paper have the authors given any definition of the different BMI groups and what constitutes underweight, overweight or anything about the different ‘grades’ of obesity. Please revise for those readers not familiar with BMI ranges. Similarly, the authors may like to explain the reason for not having BMI means for children? Doing so will give this table a lot more meaning and relevance.

Table 2.

Please check the rounding of values for incidence, prevalence and mortality. It may be preferable to have rates per 100,000 as whole numbers when above 100. Similarly, for very low numbers (e.g., 0.0) it may be better to have increased decimal points.

Please ensure units for numbers are included in tables. Overweight and obesity have <18 in the ‘diseases’ column, but what is that? Age? BMI? It is unknown without units.

Are the costs First Year (Acute Event) per capita? If so, please make clear.

Table 3.

Please check your units. Some dollars have no $ signs. Also, what do the two values for the direct medical cost, USD (million) represent? Is one Argentinian dollars and one USD? If so, please make this very clear for the reader within the table or as a footnote.

Or is it per capita/ for the whole population? As it is, no one knows.

Be careful with the text. First sentence after Table 3 shows – 639,000 which makes it look like a negative number but it’s just punctuation. Could you use brackets instead or use the dash properly.

Could you add up T2DM and CVD costs etc to show even more significant results and the significance of multiple morbidities?

Figures 2 & 3

These are nice graphs, particularly Figure 3. Where did you source the data from? This should be included in your paper.

• Discussion

Overall, the discussion needs revising to improve the flow of information. There are some interesting points the authors make, but it’s adhoc and disjointed.

Paragraph 1, use past tense for studies already done. So, ‘In this study, we estimated….’

Paragraph 3: What is BASTA? Please spell out acronyms if only being used once or twice.

Paragraphs 4 & 5: Why are the authors discussing the strengths and limitations in the middle of your discussion? These go at the end of your discussion.

Paragraph 6: Why do countries in Latin America have a high consumption of unhealthy products?

Paragraphs 7 & 8: These would be better in the introduction.

The paper has some interesting, significant findings. With revision, it will be much improved and useful for fellow modellers. All the best with the revision.

Reviewer #2: Thank you for the opportunity to review this paper, entitled ‘The Burden of Disease and Economic Impact of Sugar-Sweetened Beverages Consumption in Argentina: a Modeling Study’. The authors estimate the burden of disease and costs imparted by SSB consumption in Argentina. The authors have used a strong modelling approach to estimate this, and the both the rationale and modelling techniques appear to be sound. However, much of the manuscript should be restructured to increase comprehension and readability. Further, the authors may wish to consider their interpretation of the model, as rather than estimating the exact burden of SSBs, it instead estimates the reduce burden if consumption were reduced to a predetermined level. Finally, should this paper be accepted for publication, I suggest further editing for English language and readability.

Abstract

- As with much of the results and the discussion, please reframe to highlight that the model does not specifically estimate the cases of disease and deaths caused by SSB consumption (for example, of the 4,425 deaths mentioned, in the real world they are not only caused by SSB consumption but reducing SSB consumption may prevent them).

- Reformulating SSBs is not a good policy option to highlight in the abstract. I suggest discussing SSB taxation, marketing restrictions, or food and nutrition policies broadly.

Introduction

- The introduction is too long, and the structure makes it difficult to identify the issue being discussed. I suggest restructuring the introduction into three paragraphs:

1) Overweight, obesity and NCDs are a serious health concern globally.

2) An unhealthy diet, and consumption of SSBs is a key driver of overweight, obesity and NCDs. These are increasing worldwide.

3) In Argentina, consumption of SSBs is both high and increasing, and this is leading to an increased burden of disease.

4) Study rationale and aims

- Discussion of current policies to address unhealthy diets in Argentina should be left for the discussion.

Methods

- I feel that adding additional subheadings to the methods might clarify the approach for an audience with less economic modelling experience. For example, different sections for each of the three stages of estimating health and economic outcomes.

- Instead of a sperate section on data sources, please describe each data source as its use is first mentioned in the text.

- Please define DALYs when first used

Results

- The main epidemiological and economic parameters included in the model should be presented in the methods, not the results (assuming that these are derived from pre-existing data sets).

- Please edit the results to use people-first language. For example, instead of “Overweight and obesity burden children and adolescents the most”, use “Children and adolescents face the greatest burden of overweight and obesity”.

- Similarly, cases of obesity are not attributed to children/adolescents – children/adolescents are living with overweight and obesity.

- In table 3, please present ‘events’ before ‘deaths’

- It is difficult to say that SSBs cause 23% of all cases on diabetes, as so many factors contribute to disease. Instead, what the model estimates is that, if no SSBs were consumed, 23% of diabetes cases would be prevented. Please edit the results throughout to reflect this.

- I suggest not comparing the burden of disease across different NCDs as this implies that some are more important than others. Simply say how many cases of each would be avoided if SSB consumption was reduced to 0.

- Please reference the results of the included sensitivity analyses

Discussion

- As with the results, please be careful about directly attributing costs/deaths to SSB consumption – the model simply estimates that if SSB consumption were reduced, a certain number of costs and deaths would be prevented.

- Please mode the strengths and limitations to later in the discussion (just before the conclusion).

- The authors state (in the limitations section) that their estimates are likely an underestimation, but it is not clear why this is the case – is this because oral health was not included? Please explain further.

- Overall, the discussion would be improved by additional sections on drivers of SSB consumption and further consideration of policies. The authors discuss many policy options for addressing SSB consumption in Argentina, they may want to condense this a little and instead include more discussion on a) why SSB consumption is high (there is some discussion of advertising and prices, but there should be more on this) and b) how to implement best-practice policies (notably how to limit SSB industry influence).

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PONE-D-22-04375R1The Burden of Disease and Economic Impact of Sugar-Sweetened Beverages’ Consumption in Argentina: a Modeling StudyPLOS ONE

Dear Dr. Bardach,

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 submit your revised manuscript by Sep 24 2022 11:59PM. 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,

Vijay S. Gc, PhD

Academic Editor

PLOS ONE

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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: (No Response)

Reviewer #3: All comments have been addressed

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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 #3: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: 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: No

Reviewer #3: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have done an excellent job of revising the manuscript in light of the suggestions from both reviewers. It flows well, it is clear and great to see the amended version. Congratulations.

A few further minor corrections are required for accuracy, consistency and transparency:

• It looks like there’s a few instances where writing in the present tense have slipped through and it should be past tense. Suggest doing a final check.

• I question your definition of a PIF. It looks like the definition of a PAF.

See:

Barendregt & Veerman (2009) Categorical versus continuous risk factors and the calculation of potential impact fractions. J Epidemiol Community Health. 64:209-212. doi:10.1136/jech.2009.090274

• Your sources of epidemiological parameters require references. What might be useful is including a technical appendix where all the data sources are provided in a table.

• Where did you get the definition of SSBs from? It needs a reference.

• You need to reference the exchange rates published by the Central Bank of the country. You have included it at the bottom of Table 2, it will be consistent to include it also in your text.

• In your text regarding economic values, clarify the values are US dollars (e.g., US$ 40 million, etc.) Otherwise, it is open to interpretation, even though you indicate in the tables it is USD. You could also just highlight at the beginning of your results all monetary values are in USD. Just make it clear.

• Something has gone wrong with ‘Deaths’ in table 3. Looks like an overlap or duplication.

• Discussion. Last sentence, third paragraph

What is the age group in numbers of the ‘youngest group’? The current definition tells the reader nothing. The reader is looking for detail (e.g.,” …..’incidence occurred in the youngest group (12-18 years), particularly among men……”

All the best for the final hurdle. It will be a great paper and will attract much interest from public health researchers and policy makers alike.

Reviewer #3: The consumption of sugar-sweetened beverages is a growing public health problem. In this study, the authors analyze SSB-associated burden in Argentina, one of the countries with the highest consumption of SSB in the world.

The authors have tried to carefully model the health burden and costs of SSB use. However, given the complexity of modeling itself, the article contains little information on the process of obtaining the results. I believe that the article needs a major revision of the methodological aspects before considering its publication in Plos One.

Here is a detail of suggested changes:

Major aspects

- reviewer #1 already mentioned the importance of providing accurate and explicit information about how the modeling process was conducted, and the lack of information in this regard. I do not believe you have addressed this concern. Although I understand that space constraints precludes authors from providing extensive and detailed data, these data are still needed, and you should consider adding an appendix that contains details about your assumptions.l. This appendix should at a minimum address/include:

- the list of all outcomes evaluated and their attached RRs (used in the PIF equation)

- a clarification of how the modeling pathway worked. For example:

- How exactly does BMI affect diabetes and CVD outcomes? (the link between direct and indirect pathways). Is not clear to me looking at Figure 1.

- How did you avoid duplicity of events? For example:

- you applied a risk of mortality attached to diabetes, but then another risk for CVD outcomes. Did you exclude the population of diabetics for the latest? If not, wouldn´t there be a duplicity of CVD events among diabetics?

- In figure 1, it seems you applied an effect of BMI on CVD (then reflects events through the direct pathway), but also a BMI effect directly on outcomes, which also includes CVD events. Did you differentiate between incident and established CVD?

- Are age and gender differences in results based solely on differences on SSB consumption? How do you account for the inherent differential risk of events among different age and gender groups?

- Cost analysis: although is not explicitly mentioned, it seems the analysis only covers one year of avoided events and related costs. Nevertheless, in table 2, you include a column describing costs since 2nd year/follow up. How were they modeled? Was there any assumption regarding economic burden in previous years?

- population size assumptions, by age and gender. Source of information for population inputs (like census)

- The paper models a scenario of not only a zero SSB consumption (as if they were withdrawn from market) but also no caloric compensation at all (an aspect that should be discussed at some point in the article, and it's currently not). Numbers are therefore strikingly high regarding SSB burden. Nevertheless, the discussion barely highlights the utopic nature of the modeled scenario, and I think it should be talked through in the discussion and highlighted in limitations.

Minor changes:

Introduction:

- 3rd paragraph, first sentence: it needs a reference.

- 3rd paragraph. The sentence “People who are overweight or obese are at greater risk of developing severe health problems, such as type 2 diabetes, high blood pressure, asthma, sleep disorders, liver disease, low self-esteem, and social and emotional issues” needs a reference

- Last paragraph reads: “This manuscript presents the results for Argentina obtained through a collaborative, more comprehensive project….”. More than what?

Methods:

- For what period of time is the intervention being conducted? It seems to be 2020 (for what it says in Results) but this should be clearly stated in Methods (and in the abstract)

- You used Monte Carlo simulations to get uncertainty intervals. I wouldn't call this a sensitivity analysis since you don't compare your results under a different assumption but rather estimate the uncertainty around the result you already got. In the same way, I wouldn´t call having reported UI a strength (as you do in discussion), since uncertainty around the main results is expected to be reported in almost any study.

Conclusion

- The last sentence reads: “This study is the first to assess the health and financial burden of SSB consumption in the country, including children and a wide range of attributable conditions.”. Nevertheless, and as you mentioned previously, the BASTA study already evaluated the health burden of SSB consumption among adults in Argentina. I believe this sentence is misleading and should be rephrased.

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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 #3: 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.

Attachments

Attachment

Submitted filename: SSB IECS - Plos One submitted.docx

PONE-D-22-04375R2The Burden of Disease and Economic Impact of Sugar-Sweetened Beverages’ Consumption in Argentina: a Modeling StudyPLOS ONE

Dear Dr. Bardach,

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 submit your revised manuscript by Dec 02 2022 11:59PM. 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,

Vijay S. Gc, PhD

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.

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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: (No Response)

Reviewer #3: (No Response)

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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 #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

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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 #3: Yes

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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 #3: Yes

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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 to the authors for improving this paper. There are only minor comments that require addressing:

Abstract

• If you have changed to describe a PAF, then you need to correct the wording in the abstract (it still says you’ve used the population impact factor).

Second page of introduction, fourth paragraph:

• The text indicates adults consume 85 litres of SSB per year. In the paragraph above that, it says children and adolescents consume 40% more SSBs that adults. Does that mean children and adolescents are consuming nearly 120litres per year?

Fourth page, first line:

• The authors need to correct the first line on this page to say…..’or mortality that would occur…….’

• Fourth line: the authors need to correctly say PAF, not population impact factor, and again, in the third paragraph on the same page.

Fifth page:

• Second paragraph: A reference needs to be included for the defining of SSBs

• Second paragraph from bottom: is it possible to superscript the BMI, like so: kg/m2?

Sixth page:

• Second paragraph, third line: it should read ….’per SSB serving per day

• Direct medical costs: the authors have not included in the methods section if the costs were calculated from a societal perspective or a health perspective. Is this relevant for this micro-costing approach (not knowing what a micro-costing approach is).

Table 3

• Although the authors have indicted there’s no problem with the ‘deaths’ row in Table 3, there still seems to be a doubling up of values over each other.

Sensitivity analysis

• In the second round of reviewing, reviewer 3 mentioned uncertainty analysis using bootstrapping is not sensitivity analysis. It appears this has not been corrected?

Figures – great graphs!

A general comment: The paragraphs spacing is inconsistent throughout. Please check.

Also, the authors use the word ‘information’ to describe data. Would it be more academic to describe it as data? Finally, it may be useful to get a final proofread - there are still typos.

Reviewer #3: Thank you for the opportunity to review this revised version of the manuscript.

We appreciate the changes the authors have made with regards to our previous comments, and appreciate the inclusion of the supplementary material.

Nevertheless, we've noticed that the list of all outcomes evaluated and their attached RRs (used in the PAF equation) is still incomplete (for example: there is still no information regarding how outcomes such as asthma, musculoskeletal conditions or other conditions were modeled. If you this this is to detailed, even for the appendix, please amend the answers “Yes - all data are fully available without restriction” and “All relevant data are within the manuscript”, and specify how interested people can contact you to request the missing information.

Regarding figure 1, if we are understanding it correctly, wouldn't something like this be more accurate, with CVD and other conditions as intermediate outcomes?

If we understood it incorrectly, please rearrange it so that it is clearer.

Finally, you say “Regarding the parameters of RR of SSB on BMI, CVD, or Diabetes, no

information disaggregated by age and gender was found”. We understand that RR may not be disaggregated by age and gender. We may have not been clear in our previous comment, but what we are wondering is: How did you model the risk of CVD and other diseases inherently associated with both age and gender, independent of the added risk of diabetes, BMI, or other variables under study? (For example, CVD risk is different for a 70-year-old man in comparison with a 35-year-old woman, even if both have no diabetes and a BMI below 25). Please clarify that in the methods.

On a minor note, you are still referring to Monte Carlo simulations as “Sensitivity analysis” (results section).

I think the manuscript has improved since the previous version but still needs these relatively minor clarifications. We look forward to your answers to our comments.

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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.

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Reviewer #1: No

Reviewer #3: 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.

The Burden of Disease and Economic Impact of Sugar-Sweetened Beverages’ Consumption in Argentina: a Modeling Study

PONE-D-22-04375R3

Dear Dr. Bardach,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Vijay S. Gc, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Please correct the first sentence under the Results section in the abstract. 110,000 healthy life-years (DALYs) to 110,000 healthy life years lost to premature death and disability.

Reviewers' comments: