Association of body mass index with health care expenditures in the United States by age and sex

Zachary J. Ward; Sara N. Bleich; Michael W. Long; Steven L. Gortmaker

doi:10.1371/journal.pone.0247307

Peer Review History

Original SubmissionNovember 17, 2020
18 Dec 2020 Decision Letter - Robert Siegel, Editor PONE-D-20-36222 Association of body mass index with health care expenditures in the United States by age and sex PLOS ONE Dear Dr. Ward, 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 Jan 29 2021 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. 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PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability. Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized. Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access. We will update your Data Availability statement to reflect the information you provide in your cover letter. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: 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: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: This is a very carefully constructed analysis of the cost of continuously, in addition to categorically, measured BMI considering both age and sex with which I can find no fault in method. I have two suggestions for improvement in the paper. The first is to explain why you undertake all the corrections for self-report bias relative to NHANES rather than simply using NHANES. It seems like NHANES may not be sufficiently representative, but it is unclear as they cover the same time period. The second in the development of the conclusions. The paper set out to “To address key gaps in the literature, in this paper we estimate continuous BMI-specific medical costs by age and sex, and provide updated estimates of the medical costs attributable to obesity using recent data.” Please link back to this in the conclusions—note the higher costs of females, the comparatively low cost of children, and the high costs of 60-70 year olds. Linking back the billions of dollars in excess costs as a motivation (including opportunity cost) as an immediate call to policy action could be emphasized. Reviewer #2: I appreciate this very relevant and important topic. The data and information as presented for the obesity-related costs by BMI units as well as by BMI percentile categories is very clear. There is limited data out there for pediatrics so greatly appreciate the inclusion of pediatrics from ages 6-19 as well as your ability to control for all the many variables listed and the use of separate models for children vs adults. I did have a question about the use of z-scores in children vs the use of actual BMI values like in the adults as the use of z- scores in the literature has become somewhat controversial. You may want to consider reviewing this article below from 2017 that is similar in nature (but nto the same) to your study. The Additional Costs and Health Effects of a Patient Having Overweight or Obesity: A Computational Model Saeideh Fallah-Fini1,2, Atif Adam1, Lawrence J. Cheskin1, Sarah M. Bartsch1, and Bruce Y. Lee Obesity (2017) 25, 1809-1815. doi:10.1002/oby.21965 ****** 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/. 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Revision 1
22 Jan 2021 Author Response Additional Editor Comments: 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf We have revised the manuscript formatting and file naming to meet the style requirements. 2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information. If you are reporting a retrospective study of medical records or archived samples, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data from their medical records used in research, please include this information. Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”). For additional information about PLOS ONE ethical requirements for human subjects research, please refer to http://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research. We used public use samples of de-identified datasets which are freely available online. We have amended the Methods section of the manuscript to clarify this point. Line 24: “We used publicly available, de-identified data from the Medical Expenditure Panel Survey (MEPS) 2011-2016.” 3. You have not indicated whether ethical approval was waived or necessary for your study. We understand that the framework for ethical oversight requirements for studies of this type may differ depending on the setting and we would appreciate some further clarification regarding your research. Could you please provide further details on ethical oversight of your study. Please clarify whether or why your study is exempt from the need for approval. This work does not involve human subjects, and is thus IRB exempt. We used public use samples of de-identified datasets which are freely available online. 4. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability. Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized. Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access. We will update your Data Availability statement to reflect the information you provide in your cover letter. We have revised the cover letter to provide this information. We have also added our estimates of age/sex/BMI-specific medical expenditures to a data repository, which will be made publicly available if the analysis is accepted for publication. Lines 132-133: “BMI-specific medical costs by age and sex are available in a public repository (https://doi.org/10.7910/DVN/872OW1).” Reviewers' comments: Reviewer #1: This is a very carefully constructed analysis of the cost of continuously, in addition to categorically, measured BMI considering both age and sex with which I can find no fault in method. Thank you for your supportive comments. I have two suggestions for improvement in the paper. The first is to explain why you undertake all the corrections for self-report bias relative to NHANES rather than simply using NHANES. It seems like NHANES may not be sufficiently representative, but it is unclear as they cover the same time period. Thank you for this clarifying question. NHANES is generally considered the gold-standard for nationally-representative, measured BMI. However, NHANES does not have information on medical costs – the outcome of interest in this analysis. Although MEPS does have individual-level data on both medical costs and BMI, the BMI data are self-reported, which is well-known to cause bias – generally underestimating BMI for adults, and often overestimating it for young children. Because NHANES and MEPS are both designed to be nationally-representative samples, we can use information on the BMI distribution from NHANES to adjust MEPS data for self-reporting bias, using the corrected individual-level BMI to more accurately estimate the relationship between BMI and medical expenditures. The second in the development of the conclusions. The paper set out to “To address key gaps in the literature, in this paper we estimate continuous BMI-specific medical costs by age and sex, and provide updated estimates of the medical costs attributable to obesity using recent data.” Please link back to this in the conclusions—note the higher costs of females, the comparatively low cost of children, and the high costs of 60-70 year olds. Linking back the billions of dollars in excess costs as a motivation (including opportunity cost) as an immediate call to policy action could be emphasized. Thank you for this suggestion. We have highlighted these findings in the conclusions. Lines 194-203: “We found that health care expenditures are higher for people with excess weight across a wide range of ages and BMI levels, with especially high costs for people with severe obesity. Obesity-related medical costs are higher for adult females, and increase with age for all adults, with the highest estimated costs occurring for 60-70 year olds. Although childhood obesity contributes a small proportion of total obesity-related medical costs, because excess weight in childhood is a strong predictor of adult obesity, policies to prevent excess weight gain at all ages are needed to mitigate the health and economic impact of the obesity epidemic, which accounts for over $170 billion in excess medical costs per year in the United States. These findings highlight the importance of promoting healthy weight across the entire BMI distribution, and provide policy makers and practitioners with more accurate estimates of the health care cost impact of excess weight by age, sex, and continuous BMI.” Reviewer #2: I appreciate this very relevant and important topic. The data and information as presented for the obesity-related costs by BMI units as well as by BMI percentile categories is very clear. There is limited data out there for pediatrics so greatly appreciate the inclusion of pediatrics from ages 6-19 as well as your ability to control for all the many variables listed and the use of separate models for children vs adults. Thank you for your supportive comments. We agree that data for children are often not available, and felt it was important to include them in this analysis I did have a question about the use of z-scores in children vs the use of actual BMI values like in the adults as the use of z- scores in the literature has become somewhat controversial. Thank you for the opportunity to clarify this point. We did use the actual BMI values when estimating the models, but use the corresponding z-scores to display the predicted expenditures in the figure. We have clarified this in the manuscript. Lines 68-72: “We predicted adult expenditures for BMI values between 10 and 80. For children we predicted expenditures for BMI z-scores between -3 and +3. Although we fitted our model using BMI for both children and adults, we present the univariate predicted expenditures for children in terms of BMI z-score for visual ease, as the overweight and obesity thresholds are defined by BMI z-score for children.” You may want to consider reviewing this article below from 2017 that is similar in nature (but nto the same) to your study. The Additional Costs and Health Effects of a Patient Having Overweight or Obesity: A Computational Model Saeideh Fallah-Fini1,2, Atif Adam1, Lawrence J. Cheskin1, Sarah M. Bartsch1, and Bruce Y. Lee Obesity (2017) 25, 1809-1815. doi:10.1002/oby.21965 Thank you for this suggestion. The referenced paper estimates incremental costs over an adult’s lifetime using a Markov model, with the direct medical costs of overweight/obesity vs normal weight one of the inputs to the model, based on data from MEPS. However it is not clear that the authors adjusted for self-report bias or potential confounding when analyzing the MEPS data. Our current analysis aims to provide such cost estimates which could be used in simulation models such as this. Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0247307.r002
5 Feb 2021 Decision Letter - Robert Siegel, Editor Association of body mass index with health care expenditures in the United States by age and sex PONE-D-20-36222R1 Dear Dr. Ward, 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, Robert Siegel Academic Editor PLOS ONE Additional Editor Comments (optional): You have a successfully addressed all the reviewer concerns 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 ******** 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 ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: 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 ****** 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 ****** 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: (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 #1: No https://doi.org/10.1371/journal.pone.0247307.r003
Formally Accepted
2 Mar 2021 Acceptance Letter - Robert Siegel, Editor PONE-D-20-36222R1 Association of body mass index with health care expenditures in the United States by age and sex Dear Dr. Ward: 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 Dr. Robert Siegel Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0247307.r004

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