Trends in the prevalence of obesity and estimation of the direct health costs attributable to child and adolescent obesity in Brazil from 2013 to 2022

Eduardo Augusto Fernandes Nilson; Michele Gonçalves da Costa; Ana Carolina Rocha de Oliveira; Olivia Souza Honorio; Raphael Barreto da Conceição Barbosa

doi:10.1371/journal.pone.0308751

. 2025 Jan 16;20(1):e0308751. doi: 10.1371/journal.pone.0308751

Trends in the prevalence of obesity and estimation of the direct health costs attributable to child and adolescent obesity in Brazil from 2013 to 2022

Eduardo Augusto Fernandes Nilson ^1,^2,³, Michele Gonçalves da Costa ⁴, Ana Carolina Rocha de Oliveira ^4,^*, Olivia Souza Honorio ⁴, Raphael Barreto da Conceição Barbosa ⁴

Editor: Alanna Gomes da Silva⁵

PMCID: PMC11737795 PMID: 39820857

Abstract

Introduction

Childhood obesity is a major global public health issue globally and in Brazil. The impacts of childhood obesity include higher risk of disease during childhood and of obesity and non-communicable diseases in adulthood and represent an important epidemiological and economic burden to countries. This study aims to analyze the trends and to estimate the direct healthcare costs of childhood and adolescent obesity to the National Health System from 2013 to 2022.

Methods

We used Prais-Winsten regressions for determining the trends in the prevalence of obesity and modeled the attributable to childhood and adolescent obesity in the Brazilian National Health System using previous meta-analysis of studies.

Results

The hospitalizations of children and adolescents with obesity as a primary cause totaled Int$2.6 million to the Brazilian National Health System from 2013 to 2022, demonstrating that obesity is rarely considered as a cause of hospitalization especially among children and adolescents. The additional costs of hospitalizations attributable to childhood obesity totaled Int$101.5 million during the same period. The additional non-hospital, outpatient and medication cost attributable to childhood obesity in Brazil were estimated at Int$6.0 million, so the total estimated healthcare costs were of approximately Int$107.5 million in the last decade.

Conclusion

This study highlights that childhood and adolescent obesity are increasing for most age-groups and that its costs are not limited to the economic impacts on adult health and represent a relevant economic burden to the Brazilian National Health System and to families because of additional costs during childhood and adolescence. Therefore, the prevention and control of childhood and adolescent obesity must be public health priorities.

Introduction

Childhood and adolescent obesity currently represent major public health challenges. Globally, in 2020, there were approximately 175 million children over 5 years of age and adolescents with obesity and, if current trends are not modified, this number may increase to 383 million children and adolescents by 2035 [1].

Despite the lack of regular national nutritional surveys on child nutrition over the last decade, the prevalence of obesity among Brazilian children under 12 years of age was estimated at 12.2% in a recent systematic review [2]. Additionally, the prevalence of obesity among children from 5 to 9 years of age accompanied by public Primary Health Care facilities reached 13,2% in 2018 [3]. For adolescents, national surveys showed a gradual increase in the prevalence of overweight and obesity over the last decades [4].

A growing body of evidence has demonstrated that, compared to children with adequate weight, children with obesity have a higher risk of health issues during childhood, such as type-2 diabetes, hypertension, asthma, sleep apnea, musculoskeletal problems and metabolic disorders, as well as lower self-esteem, higher risk of bullying and lower school performance [5]. Additionally, children and adolescents with obesity face higher risk of health issues in adulthood and childhood obesity is a string predictor of adult obesity and risk of non-communicable diseases such as type-2 diabetes, cardiovascular diseases, and some types of cancers. The future impacts of childhood obesity also include negative socioeconomic and workforce consequences, including reduced employability, lower productivity and salaries [6].

Considering this association between obesity during childhood and adolescence and negative outcomes in adulthood, many studies have started to project the impacts of childhood obesity on morbidity and mortality associated with comorbidities and the direct costs of treating these diseases and also the indirect costs to society related to premature mortality and retirement and losses of productivity due to absenteeism and presenteism [7–11].

Despite inclusive evidence on the increased risk of hospitalization among children and adolescents with obesity, strong evidence has demonstrated that childhood obesity is associated with higher risk of visits to emergency rooms [12,13] and higher risks of hospitalization and acute infection by diseases such as influenza e Covid-19 [14,15].

A number of studies showed that children and adolescents with obesity have higher costs of hospitalizations, outpatient procedures, prescription medications and non-hospital costs [5,16–20]. Based on these primary studies, a recent systematic review and meta-analysis compared the healthcare costs of children and adolescents with obesity to those with normal BMI (body-mass index) and found increased annual total medical costs attributable to childhood overweight and obesity of $237.55 per capita and annual direct and indirect costs of $13.62 billion, which were projected to reach $49.02 billion in 2050 [21].

In Brazil, previous studies have estimated the economic burden of obesity-related diseases among adults to the National Health System (Sistema Único de Saúde–SUS) [22,23], however, there is a need to develop studies on the attributable to childhood and adolescent obesity. Therefore, this study aims to fill a knowledge gap regarding the economic burden of child and adolescent obesity in Brazil. The objectives of this study are to analyze the trends in the prevalence and to estimate the direct healthcare costs of childhood and adolescent obesity to the National Health System from 2013 to 2022.

Methods

This study is based on the estimation of the trends in the prevalence of childhood and adolescent obesity and the modeling of total costs of hospitalizations and the additional costs attributable to childhood and adolescent obesity in the Brazilian National Health System from 2013 to 2022. For the purposes of this study, because of the age disaggregation available in the public reports of the national health information systems, we considered individuals from 0 to 9 years of age as children and those aged 10 to 19 years as adolescents [24].

The modeling is divided in the following steps: (I) fitting the prevalence of childhood and adolescent obesity from 2013 to 2022 through a linear regression analysis; (II) estimating the percentage of additional hospitalization costs of children and adolescents with obesity compared to those without obesity; (III) extracting the data on the total number and average per capita costs of hospitalizations; (IV) extracting and adjustment of data on the prevalence of obesity among children and adolescents that were monitored by Primary Healthcare services; (V) estimating the number of hospitalizations and the average per capita cost of hospitalizations among children and adolescents with obesity and those with adequate BMI; (VI) estimating the total costs of hospitalizations of children and adolescents with obesity and the additional costs compared to those with adequate BMI.

Trends in child obesity

The information on the prevalences of obesity among individuals monitored by the public primary healthcare services by age group (0 to 4 years, 5 to 9 years, and 10 to 19 years) for each year from 2012 to 2022 were obtained from publicly available reports from the Food and Nutrition Information System–Sisvan [25].

The trends in the changes in the prevalence of obesity among children and adolescents were estimated through the Prais-Winsten method [26] for each age group.

Cost analysis

Firstly, before estimating the total costs of hospitalizations of children and adolescents with obesity and the additional costs attributable to childhood obesity, we extracted the hospitalization costs which primary cause was declared as obesity in the National Hospital Information System from 2013 to 2022 by age and sex groups to analyze how childhood obesity is considered a disease by health professionals in the National Health System.

Then, as the first step for estimating the hospitalization costs attributable to childhood and adolescent obesity, we calculated the average percentage of additional hospitalization costs of children and adolescents with obesity compared to those with adequate BMI based on a selection of the 24 primary studies on the healthcare costs of childhood and adolescent obesity that were included in the meta-analysis by Ling et al, 2023 [21]. The studies had variable sample sizes and included children and adolescents from 0 to 19 years of age, and the estimated percentage of additional hospitalization costs of children and adolescents with obesity was of 16.46% (CI 95%: 1.98%-30.94%), as detailed in the Supplementary Materials.

This approach was used because there are no available studies comparing the costs of hospitalization between children and adolescents with obesity and those with adequate BMI in Brazil. This methodological approach also intends to avoid directly multiplying the estimated costs found in the meta-analysis because of the differences considering the organization and coverage of health systems and because all studies included in the meta-analysis were conducted in high income countries, therefore the attributable costs could be overestimated if the absolute values were considered.

Afterwards, we extracted the average per capita costs for all hospitalizations and the total number of hospitalizations from 2013 to 2022 for each age group (1 to 4 years, 5 to 9 years, 10 to 14 years, and 15 to 19 years) from the National Hospital Information System–SIH/SUS [27]and converted the currency using the Purchasing Power Parities estimated by the Organisation for Economic Co-operation and Development [28].

The trends on the nutritional status of children and adolescents (obese and non-obese) were considered as proxies of the nutritional status of the population that predominantly uses the public health system.

We conservatively assumed that children and adolescents with obesity had the same risk of hospitalization from all causes of those with adequate BMI to estimate the number of hospitalizations among children and adolescents with obesity based on the prevalence of obesity by age-group for each year of the analysis.

The additional costs attributable to childhood and adolescent obesity were estimated by multiplying the additional average costs and the total number of hospitalizations of children and adolescents with obesity.

Finally, the additional non-hospital costs, together with outpatient and medication costs were estimated assuming that they would keep the proportionality to the additional hospitalization costs estimated by Ling et al [21].

All data used in the modeling study are summarized in Table 1.

Table 1. Data inputs for the estimation of time trends in childhood and adolescent obesity and of its direct healthcare costs.

Parameter	Outcome	Comments	Source
Childhood obesity	Prevalence of children and adolescents with obesity (%)	Stratified by age and sex	National Food and Nutrition Surveillance System–Sisvan [25]
Additional healthcare costs attributable to childhood obesity	Percentage of additional healthcare costs among children and adolescents with obesity (%)		Ling et al, 2023 [21]
Number of hospitalizations	Total hospitalizations of children and adolescents from all-causes in the National Health System (number)	Stratified by year and age-group	National Hospital’ Information System (SIH/SUS) [27]
Costs of hospitalizations	Costs of hospitalizations from all-causes to the National Health System (Int$)	Stratified by year, age and sex	National Hospital’ Information System (SIH/SUS) [27]

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Sensitivity analysis

The robustness of the model assumptions and its data inputs was assessed through sensitivity analysis changing the original model parameters and comparing the results to the primary model. The modeled scenarios included: using non-adjusted prevalences of obesity in the population, proportionally adjusting the incidence of non-communicable diseases associated with high body mass index considering the differences between Brazil and the United States of America using data from the Global Burden of Disease (GBD) Study [29] and altering the estimated percentage of additional costs of hospitalizations in ±5%.

Further details of the parameters for the estimations and the modeling methodology are described in the Supplementary Materials.

Results

According to the Brazilian health information systems, obesity has different trends among children and adolescents according to their age-group (Table 2). For children under 5 years of age, the prevalence of obesity showed a small reduction from 2013 to 2022 (2.97% decrease per year), starting at 8.46% in 2013 and reaching 6.63% in 2022. The prevalence of obesity increased from 11.92% to 16.21% among children of 5 to 9 years of age (3.03% increase per year) and from 5.77% to 12.78% among adolescents (6.48% increase per year).

Table 2. Childhood and adolescent obesity trends in Brazil from 2013 to 2022, by age-group.

Age-group	Prevalence 2013	Prevalence 2022	Annual % increment rate (95% CI)	p-value	Situation
0 to 4 years	8.46%	6.63%	-2.969% (-4.802%-1.136%)	0.006	Decreasing
5 to 9 years	11.92%	16.21%	3.033% (1.087%-4.980%)	0.007	Increasing
10 to 19 years	5.77%	12.78%	6.484% (5.054%-7.914%)	<0.001	Increasing

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According to information from the National Hospital Information System, show in Table 3, obesity is rarely considered as a primary cause of hospitalization of children of 1 to 9 years. For adolescents, the total number and the costs of hospitalizations having obesity as a primary cause is higher, especially for those aged 15 to 19 years (95% of the hospitalizations, costing Int$2.57 million). For this age group, the number of hospitalizations and their corresponding costs gradually increase and peak in 2018–2019 (reaching close to Int$406 thousand per year), but the number of hospitalizations and their costs decreased significantly in 2020 and 2021 and start to increase again in 2022.

Table 3. Total number and costs of hospitalizations with obesity as a primary cause in the Brazilian National Health System (SUS) (Int$), Brazil 2013–2022.

Idade	2013	2014	2015	2016	2017	2018	2019	2020	2021	2022
1 to 4 years
Number	0	1	1	0	0	1	0	1	0	1
Costs	0	34	584	0	0	520	0	23	0	192
5 to 9 years
Number	0	0	1	2	3	1	0	3	3	1
Costs	0	0.00	28	3,000	224	419	0	253	4,421	155
10 to 14 years
Number	4	2	2	3	2	2	4	2	2	4
Costs	3,333	690	3,241	6,709	3,214	3,184	792	4,800	2,396	681
15 to 19 years
Number	86	72	100	128	143	143	147	38	24	43
Costs	264,541	236,139	294,646	358,571	387,932	402,333	391,264	91,414	46,921	92,952

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The hospitalization costs with children and adolescents with obesity totaled Int$718.52 million over the last decade (CI 95% Int$629.20–807.84 million) and the additional costs compared to individuals with adequate BMI totaled Int$101.56 million (CI 95% Int$88.93–114.18 million) from 2013 to 2022 (Table 4).

Table 4. Total costs and estimated attributable costs to obesity of hospitalizations in the Brazilian National Health System (SUS) among children and adolescents (Int$), Brazil 2013–2020.

	Total hospitalization costs	Additional hospitaliztion costs
1 to 4 years	197,910,034	27,973,681
	(173,307,797–222,513,083)	(24,496,267–31,451,210)
5 to 9 years	182,907,985	25,853,210
	(160,170,656–205,646,065)	(22639392–29067134)
10 to 14 years	95,567,543	13,508,037
	(83,687,522–107,447,956)	(11,828,850–15,187,280)
15 to 19 years	242,131,636	34,224,203
	(212,032,202–272232063)	(29,969,785–38,478,761)
Total	718,517,199	101,559,132
	(629,198,176–807,839,167)	(88,934,295–114,184,385)

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During the last decade, the total non-hospital healthcare costs paid by the families, the outpatient costs and the costs of medications were estimated at a total of Int$43.20 million CI 95% Int$37.83–48.57 million), of which Int$6.02 million (CI 95% Int$5.28–6.77 million) represented additional costs attributable to childhood obesity (Tables 5 and 6). Among these costs, the healthcare costs paid by the families represent 47,6% of these additional costs (R$2.91 million).

Table 5. Estimated non-hospital, outpatient and medication costs of children and adolescents with obesity, Brazil 2013–2020.

	Non-medical costs	Outpatient costs	Medication costs	Total
1 to 4 years	5,663,562.20	1,587,210.30	4,647,487.87	11,898,260.37
	(4,959,523.6–6,367,624.01)	(1,389,903.86–1,7845,23.25)	(4,069,757.69–5,225,237.11)	(10,419,185.15–13,377,384.37)
5 to 9 years	5,234,250.77	1,466,896.00	4,295,197.29	10,996,344.06
	(4,583,579.97–5,884,943.03)	(1,284,545.85–1,649,252.16)	(3,761,260.42–4,829,151.76)	(9,629,386.24–12,363,346.95)
10 to 14 years	2,734,842.25	766,438.09	2,244,196.45	5,745,476.79
	(2,394,873.44–3,074,822.27)	(671,162.01–861,717.31)	(1,965,219.93–2,523,182.18)	(5,031,255.38–6459721.76)
15 to 19 years	6,929,045.22	1,941,861.25	5,685,936.26	14,556,842.73
	(6,067,694.7,790,424.68)	(1,700,468.07–2,183,262.38)	(4,979,116.34–6,392,779.49)	(12,747,278.59–16,366,466.55)
Total	20,561,700.44	5,762,405.63	16,872,817.87	43,196,923.95
	(18,005,671.19–23,117,813.99)	(5,046,079.79–6,478,755.1)	(14,775,354.38–18,970,350.54)	(37,827,105.36–48,566,919.63)

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Table 6. Estimated additional non-hospital, outpatient and medication costs of children and adolescents with obesity for families and the Brazilian National Health System (SUS), Brazil 2013–2020 (average and 95% Confidence Intervals).

	Non-medical costs	Outpatient costs	Medication costs	Total
1 to 4 years	800,518.70	202,112.56	656,901.23	1,659,532.49
	(701,006.05–900,034.63)	(176,987.91–227,238.04)	(575,241.7–738,563.45)	(1,453,235.66–1,865,836.12)
5 to 9 years	739,837.50	186,791.95	607,106.57	1,533,736.02
	(647,868.15–831,809.89)	(163,571.81–210,012.86)	(531,637.02–682,578.6)	(1,343,076.98–1,724,401.35)
10 to 14 years	386,557.50	97,596.88	317,206.95	801,361.34
	(338,504.46–434,612.13)	(85,464.59–109,729.57)	(277,774.89–356,640.32)	(701,743.94–900,982.02)
15 to 19 years	979,388.97	247,273.19	803,681.18	2,030,343.33
	(857,640.92–1,101,141.03)	(216,534.61–278,012.78)	(703,775.4–903,590.25)	(1,777,950.93–2,282,744.06)
Total	2,906,302.67	733,774.58	2,384,895.93	6,024,973.18
	(2,54,5019.58–3,267,597.67)	(642,558.91–824,993.26)	(2,088,429.02–2,681,372.61)	(5,276,007.51–6,773,963.54)

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Therefore, considering the sum of total hospital, non-hospital, outpatient, and medication costs with children and adolescents with obesity was estimated at almost Int$761.71 billion (CI 95% Int$667.03–856.41 million) from 2013 to 2022, and the additional costs attributable to childhood obesity totaled approximately Int$107.58 million (CI 95% Int$94.21–120.96 million) during the last decade.

In the sensitivity analysis, the estimated with different parameters generated small differences, between -3% and +3%, when compared to the results of the primary model.

Discussion

This study firstly investigated the trends in childhood and adolescent obesity and the estimated healthcare costs with children and adolescents with obesity. During this period, the prevalence of obesity has decreased 3.0% per year among children under 5 years of age monitored by primary healthcare services, but it has increased significantly among of those aged 5 to 9 years (3.0% per year) and 10 to 19 years (6.5% per year).

The results for adolescents are consistent with the existing national surveys, which have reported a gradual increase in adolescent obesity over the last decades [30,31], while there is a lack of more frequent recent national surveys for children during this period to compare our time trends. However, prevalence of obesity according to a 2019 survey for children under 5 years of age [32]was almost half of that found for children accompanied by primary health care services in our study, demonstrating that children that depend on the National Health System are likely to be more vulnerable to the double burden of malnutrition.

Regarding the healthcare cost analysis, the hospitalizations of children and adolescents with obesity as a primary cause totaled Int$2.6 million to the Brazilian National Health System from 2013 to 2022, mostly among adolescents from 15 to 19 years. This demonstrates that obesity is rarely considered as a cause of hospitalization especially among children and adolescents.

Meanwhile, the additional costs of hospitalizations attributable to childhood obesity totaled Int$101.56 million during the same period. Considering the additional non-hospital, outpatient and medication cost attributable to childhood obesity in Brazil, the total additional healthcare costs attributable to obesity were estimated at Int$107.58 million in the last decade. As a comparison, from 2013 to 2022, the total hospitalization costs of children and adolescents from all causes in chapter 4 of the International Code of Diseases (ICD-10), which encompasses endocrine, nutritional, and metabolic diseases, including malnutrition, micronutrient deficiencies, diabetes, and obesity), totaled Int$71.7 million.

These estimates demonstrate that the additional costs attributable to childhood obesity represent a large burden to the National Health System and to the families and, considering the current trends, they tend to increase in the future, together with the added risks of obesity and NCDs in adulthood, which will generate an even larger direct and indirect costs to the country. In 2018, the attributable costs of obesity the National Health System among adults were estimated at Int$637 million [23]and future projections indicate that the direct and indirect costs of obesity may represent up to 4.66% of the Gross Domestic Product in 2060, totaling US$218.2 billion [33].

Healthcare costs vary among the Brazilians, according to factors such as household income, location, race, sex, and age, and approximately 70% of the population depends on the National Health System, with higher coverages among low-income households, rural communities, and among the black population [34]. The out of pocket healthcare expenditures of people with obesity and overweight are higher than those with adequate BMI, because they spend more on medications, medical insurance, exams, and medical consultations, and have been estimated at R$249 (Int$192) per family monthly in 2008–2009 [35].

Additionally, if the current trends of increase in overweight and obesity in Brazil are maintained until 2030, their prevalences among adults may reach 68.1% and 29.6%, respectively [36]. This growth is estimated to result in 5.26 million new cases and 808 thousand deaths from outcomes such as cardiovascular diseases, diabetes, cancers and chronic kidney disease until the end of the decade [37] and represent almost Int$2 billion in terms of direct healthcare costs and Int$20 billion in losses due to premature deaths in the country[38]. Although the prevalence of non-communicable diseases tends to be higher among black people compared to the white, no studies have assessed these inequities in association with obesity in Brazil [39–41].

These trends are strongly associated with the nutritional transition in Brazil, in which traditional diets, based on foods as rice, beans, fruits and vegetables are gradually being replaced by ultra-processed products in all age groups, including children and adolescents [42]. According to the National Study on Child Food and Nutrition (Enani 2019), some 80% of children under 2 years of age have already consumed ultra-processed foods, which represents a premature exposure to unhealthy foods and does not follow the recommendations of the Brazilian Dietary Guidelines for Children Under 2 Years[43].

Similarly, the national studies on adolescent health, such as the National School Health Survey, which evaluated adolescents from 13 to 17 years old in 2019, observed that although the consumption of sugar sweetened beverages slightly reduced compared to 2015, there is a very high frequency of consumption of ultra-processed foods and low consumption of fruits among the students [44].

Also concerning, the results from the 2017–2018 Household Budget Survey (POF) show that the participation of ultra-processed foods in the total energy of the diets of adolescents is even higher that of the adults. i.e. 26.7% compared to 19.5% of the total calories of the diet [45].

There are other equity concerns in this regard, considering that the prevalences of obesity and the consumption of ultra-processed foods have increased more rapidly among lower income families [46,47]. These socioeconomic concerns also impact of food availability and prices, because, since the Covid-19 pandemic, the food patterns based on ultra-processed foods has become cheaper than the fresh and minimally processed foods, such as fruits, vegetables and whole grains [48]. Additionally, with the loss of income and jobs during the pandemic, many people abandoned supplementary health coverage to use the public health system.

Notably, the consumption of ultra-processed foods has been associated with higher risk of overweight and obesity [49]and of other NCDs, including cardiovascular diseases, diabetes and some types of cancers [50–52]. Also, the consumption of added sugar by Brazilians is high in all age-groups and requires effective public policy responses [45]. Therefore, multicomponent and intersectoral strategies are required to reduce and control obesity in all age groups, especially among children and adolescents, considering regulatory and fiscal policies, nutritional education, healthy food procurement and other policies.

The results of this study demonstrate the need for strengthening and expanding the control and prevention of childhood obesity in Brazil, considering more cost-effective interventions for treating overweight and obesity and promoting regulatory and fiscal policies that promote heathy dietary environments during all phases of childhood and adolescence, from promoting breastfeeding and complementary feeding to regulating school canteens, regulating food marketing, improving nutritional labeling, taxing ultra-processed foods and beverages and creating subsidies for fresh and minimally processed foods [53–55]. In parallel, education on healthy diets should be provided for all age groups based on the recommendations of the existing national dietary guidelines [56,57].

The strengths of this study include using a modeling method that was based on primary studies from a recent meta-analysis on the costs of childhood obesity and overweight in different countries and the use of updated data on nutritional status and costs of hospitalizations from national health information systems. The results in this study are proportionally lower than estimated additional costs of hospitalizations attributable to childhood obesity [21], because we assumed conservative parameters in the modeling and costs were mostly limited to the National Health System and does not include the costs of primary healthcare services. Also, if the costs of overweight were included in the estimations, the additional costs would be even higher.

The limitations of the study include the use of estimates of hospitalization costs from high-income countries for the modeling, the possible coverage and quality limitations of the national data sources, and not including primary healthcare costs and costs from the supplementary (private) health services in Brazil.

However, the assumptions that were adopted in this study allowed the first conservative estimation of direct costs of hospitalizations attributable to childhood obesity in Brazil. In the future, new studies will be important for direct and more precise assessment of these costs using data linkage of information from the national health information systems and possibly information from national childhood cohorts.

In conclusion, the results of this study highlight that the prevalence of childhood and adolescent obesity is increasing in most age-groups and that their costs are not limited to the impacts on adult health and represent a relevant economic burden to the Brazilian National Health System and to families because of additional healthcare costs during childhood. Therefore, the prevention and control of childhood and adolescent obesity are public health priorities that demand effective policies.

Supporting information

S1 Table. Data from the primary studies selected for the estimation of the percentage of additional hospitalization costs attributable to childhood obesity (sample size, percentage of additional costs per study, author and year of publication, country of the study, and age-group studied) and the final estimates.

(DOCX)

pone.0308751.s001.docx^{(38.8KB, docx)}

S2 Table. Total costs of hospitalizations (Int$) from all causes of children and adolescents by age-group from 2013 to 2022 (National Hospital Information System—SIH/SUS).

(DOCX)

pone.0308751.s002.docx^{(16.1KB, docx)}

S3 Table. Average per capita costs of hospitalizations (Int$) from all causes of children and adolescents by age-group from 2013 to 2022 (National Hospital Information System—SIH/SUS).

(DOCX)

pone.0308751.s003.docx^{(15.5KB, docx)}

S4 Table. Total number of hospitalizations from all causes of children and adolescents by age-group from 2013 to 2022 (National Hospital Information System—SIH/SUS).

(DOCX)

pone.0308751.s004.docx^{(15.6KB, docx)}

S5 Table. Original and adjusted prevalence of obesity by age-group from 2013 to 2022 (Sisvan).

(DOCX)

pone.0308751.s005.docx^{(15.9KB, docx)}

S6 Table. Total number of individuals monitored by Sisvan from 2013 to 2022, by age-group.

(DOCX)

pone.0308751.s006.docx^{(15KB, docx)}

S7 Table. Proportion of non-hospital, outpatient and medication costs in relation to the hospitalization costs from Ling et al, 2023 [21].

(DOCX)

pone.0308751.s007.docx^{(13.9KB, docx)}

S1 Fig. Sensitivity analysis comparing the primary model to different data input scenarios.

(DOCX)

pone.0308751.s008.docx^{(28.3KB, docx)}

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0308751.r001

Decision Letter 0

Alanna Gomes da Silva

23 Nov 2023

PONE-D-23-37832Estimation of the direct health costs attributable to child obesity in Brazil from 2013 to 2022PLOS ONE

Dear Dr. de Oliveira ,

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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Additional Editor comments:

The work entitled "Estimation of the direct health costs attributable to child obesity in Brazil from 2013 to 2022" is of great relevance to public health, especially considering the nutritional transition and the obesity epidemic affecting almost everyone, with an alarming impact on children and adolescents. The article is written with clarity and scientific rigor, but after careful reading, I made some suggestions on specific points in the text that require corrections, especially in the methods. After review, the manuscript may be accepted.

INTRODUCTION

Update references 1, 2, and 3 as the data is quite old (2009 for Brazil and 2016 worldwide) and may not represent the current scenario.

The authors state that there are no studies on the cost of childhood obesity to the SUS (Brazil's Unified Health System). Did the authors conduct a literature review to obtain this information?

The study's objective is "...to estimate the direct healthcare costs...," but the introduction does not mention the meaning of "direct healthcare costs." It is important to define this term for a better understanding of the topic.

Another issue regarding the objectives: the methods and results present information beyond costs, as the trend of obesity is analyzed. Therefore, the study will have two objectives: the first is to analyze the trend and the second is to estimate direct healthcare costs. I suggest adding this objective to make it consistent with the results. Also, objectives should be included in the abstract.

METHODS

The methods need to be clearer and more complete, following the checklist for observational studies (STROBE), which should include the following information: Study design; Setting; Participants; Variables; Data sources/measurement; Bias; Study size; Quantitative variables; Statistical methods. Available at: https://www.strobe-statement.org/checklists/

I also suggest that the part about trend analysis be more detailed, explaining how this variable is presented by Sisvan, if there is the number of children and adolescents in the system each year. Did the authors consider using the Prais-Winsten regression?

The authors work with Average Annual Percent Change but did not consider the regression p-value to determine if the change was significant. I suggest adding this and including it in the results.

Another issue that needs justification is the age cutoff of up to 19 years. According to the Brazilian Statute of the Child and Adolescent, a person is considered a child up to twelve incomplete years of age, and an adolescent is between twelve and eighteen years of age.

DISCUSSION

The authors correctly start the discussion by summarizing the results. However, the trend is not mentioned. If it is in the results, it cannot be ignored. The authors discussed the increasing trend of obesity due to nutritional transition, so it is important to mention this result in the first paragraph and follow the sequence presented in the results: first, the trend, and then the costs.

The authors present data from studies showing adolescents' dietary issues but do not mention the National School Health Survey, which provides this information and is representative of the Brazilian population.

CONCLUSION

Review the conclusion, as it should strictly address the study's objectives. Therefore, the main findings of the study should be added initially, also altering the abstract.

We look forward to receiving your revised manuscript.

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PLoS One. 2025 Jan 16;20(1):e0308751. doi: 10.1371/journal.pone.0308751.r002

Author response to Decision Letter 0

15 May 2024

Thank you for the comments and suggestions to the original manuscript, especially regarding the regression methodology that would be preferable for the analysis. We have revised the manuscript accordingly.

Attachment

Submitted filename: Point by point responses.docx

pone.0308751.s009.docx^{(17KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0308751.r003

Decision Letter 1

Alanna Gomes da Silva

16 Jun 2024

PONE-D-23-37832R1Estimation of the direct health costs attributable to child obesity in Brazil from 2013 to 2022PLOS ONE

Dear Dra. de Oliveira,

Please submit your revised manuscript by Jul 31 2024 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'.

We look forward to receiving your revised manuscript.

Kind regards,

Alanna Gomes da Silva, PhD

Academic Editor

PLOS ONE

Additional Editor Comments:

Dear Oliveira,

After the initial review, other reviewers were invited to review the manuscript and we sent it for corrections.

After careful review, we believe that the manuscript has the potential for publication, however, it will require " Major Revision" throughout the text. I request that you respond to all inquiries in a separate document and that all changes in the text be highlighted in a different color. Consider the latest corrected version submitted by the authors in May 2024.

Several issues need to be addressed: Additionally, the manuscript is not formatted according to the citation and reference style required by the journal, which adopts the "Vancouver Style." Therefore, citations should be numerical and superscripted after the period at the end of each paragraph. Please carefully review the "Submission Guidelines" criteria, available at: https://journals.plos.org/plosone/s/submission-guidelines#loc-manuscript-organization, and make all necessary corrections.

[Note: HTML markup is below. Please do not edit.]

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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: 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

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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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: Exclude the excerpt below from the results and include in the methodology:

For the estimation of the additional percentage of per capita hospitalization costs, we

selected 24 of the primary studies comparing children and adolescents with obesity and

Those with adequate BMI primary from the meta-analysis by Ling et al, 2023. The

studies had variable sample sizes and included children and adolescents from 0 to 19

years of age, and the estimated percentage of additional hospitalization costs of children and adolescents with obesity was of 16.46% (CI 95%: 1.98%-30.94%).

Include in the results: How many hospitalizations were retrieved from the National Hospital Information System SIH/SUS, in the period from 2013 to 2022, for each age group (1 to 4 years, 5 to 9 years, 10 to 14 years and 15 to 19 years) ?

Reviewer #2: Thank you for the opportunity to review the article and learn from the authors. Below I consider some points, which I consider key to aligning the article and bringing greater clarity. Some questions still need improvement for greater reader understanding.

I suggest following the strobe.

The title of the study must be connected to the objective. It is not mentioned in the title that the study covers adolescents.

Summary

I suggest including the objective of the study in the introduction of the abstract. It is important that the objective is mentioned so that the reader understands whether the methods adopted achieve these objectives.

Insert the metrics used in the methods.

Introduction

The authors mention gaps related to child surveys, which actually happens. However, for adolescents we have an important survey, the National School Health Survey, which also measures risk and protective factors for chronic non-communicable diseases, including obesity. I think it is essential to bring this information.

Another issue that I suggest should be better addressed is the problem of the study. Furthermore, how does the study advance and contribute in relation to the others?

Methods

On page 10, line 85, and in places where the authors mention the Brazilian National Health System, I suggest that it be included in parentheses with the nomenclature of the SUS (Sistema Único de Saúde – SUS in Portuguese), since it is the form used in the country.

What information and reporting systems were used? It is important to mention them from the beginning so that the reader understands the data sources used. These sources are mentioned below, I suggest mentioning them all from the beginning and then bringing the source used in detail in each subtopic. It becomes clearer for the reader.

What references did the authors use to define children and adolescents?

On page 11, line 107, I suggest including the trend of obesity in adolescents in the subtopic, as it covers the age range from 10 to 19 years old.

What was the sample studied?

What were the inclusion and exclusion criteria for the study.

On page 40, line 224, the authors mention that adjustments were made for the incidence of chronic non-communicable diseases, was it possible to obtain this information?

Results

Which final sample made up the analyzed strata.

The results in the first paragraph present obesity trends in children and adolescents, but this does not appear in the objective. This way it becomes disconnected. I suggest that it be included in the title, objective and aligned throughout the text.

Prevalence confidence intervals are not presented. Were they calculated?

Align the title of table 2 with the inclusion of the adolescent population and the sources of information used.

Tables 3, 4, 5 and 6 include the population studied and the sources of information used.

In the results, it is not possible to discuss the findings with the COVID-19 pandemic, I suggest that this appears in the discussion, as the pandemic was not even mentioned in the introduction. The results must follow the objective and methods. This can be found in the presentation of results in table 3.

Discussion

In the first paragraph it is mentioned that obesity trends in the target population were studied, but this does not appear in the objective as mentioned previously.

The conclusion needs to respond to the objective.

I suggest that the limitations and then the strengths of the study are presented in a sequential manner. On page 21, on line 430, start with the limitations, then talk about the strengths and continue with the paragraph on the conservative approach to calculating costs.

In the discussion it is important that the authors bring information from the National School Health Survey, which has already had 4 editions and the National Health and Demographic Survey, even with the last edition in 2006, it brought information about children and this research is in the field. These are important surveys with children and adolescents that also address topics related to the content of the article, they are the broadest surveys with this population that we have at a national level.

The discussion is fragile, I suggest that the results of this study be discussed in more detail. What explain the significant results in the tables? How, for example, does obesity decrease between 0 and 4 years old and increase in other age groups? In the discussion nothing was mentioned about the COVID-19 pandemic, I think it would be interesting to bring up what they mentioned about it in the results and discuss it.

Why do they assume that hospital costs were lower than literature data that did not include the supplementary health system? This needs to be better explained. What is the reason?

Furthermore, obesity is also related to availability, as well as food choice, ultra-processed foods tend to be more affordable and can lead to obesity, on the other hand, vegetables and fruits are more expensive. This needs to be discussed in the various socioeconomic strata because it will lead to obesity, whether in those who use the SUS or those who use supplementary healthcare. Furthermore, after the pandemic, many people lost their health insurance, and there is the duality of obesity and access to food and malnutrition and hunger. I suggest discussing this.

**********

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Reviewer #1: Yes: TÉRCIA MOREIRA RIBEIRO DA SILVA

Reviewer #2: Yes: Ana Carolina Micheletti Gomide Nogueira de Sá

**********

PLoS One. 2025 Jan 16;20(1):e0308751. doi: 10.1371/journal.pone.0308751.r004

Author response to Decision Letter 1

22 Jul 2024

As requested by the review letter, we are sending you the files “Response to Reviewers”, “Manuscript” and “Revised Manuscript with Track Changes”.

Attachment

Submitted filename: Point by point responses.docx

pone.0308751.s010.docx^{(17KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0308751.r005

Decision Letter 2

Alanna Gomes da Silva

25 Jul 2024

Estimation of the direct health costs attributable to child obesity in Brazil from 2013 to 2022

PONE-D-23-37832R2

Dear Dr. Oliveira,

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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Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0308751.r006

Acceptance letter

Alanna Gomes da Silva

11 Sep 2024

PONE-D-23-37832R2

PLOS ONE

Dear Dr. de Oliveira,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

(DOCX)

pone.0308751.s001.docx^{(38.8KB, docx)}

S2 Table. Total costs of hospitalizations (Int$) from all causes of children and adolescents by age-group from 2013 to 2022 (National Hospital Information System—SIH/SUS).

(DOCX)

pone.0308751.s002.docx^{(16.1KB, docx)}

S3 Table. Average per capita costs of hospitalizations (Int$) from all causes of children and adolescents by age-group from 2013 to 2022 (National Hospital Information System—SIH/SUS).

(DOCX)

pone.0308751.s003.docx^{(15.5KB, docx)}

S4 Table. Total number of hospitalizations from all causes of children and adolescents by age-group from 2013 to 2022 (National Hospital Information System—SIH/SUS).

(DOCX)

pone.0308751.s004.docx^{(15.6KB, docx)}

S5 Table. Original and adjusted prevalence of obesity by age-group from 2013 to 2022 (Sisvan).

(DOCX)

pone.0308751.s005.docx^{(15.9KB, docx)}

S6 Table. Total number of individuals monitored by Sisvan from 2013 to 2022, by age-group.

(DOCX)

pone.0308751.s006.docx^{(15KB, docx)}

S7 Table. Proportion of non-hospital, outpatient and medication costs in relation to the hospitalization costs from Ling et al, 2023 [21].

(DOCX)

pone.0308751.s007.docx^{(13.9KB, docx)}

S1 Fig. Sensitivity analysis comparing the primary model to different data input scenarios.

(DOCX)

pone.0308751.s008.docx^{(28.3KB, docx)}

Attachment

Submitted filename: Point by point responses.docx

pone.0308751.s009.docx^{(17KB, docx)}

Attachment

Submitted filename: Point by point responses.docx

pone.0308751.s010.docx^{(17KB, docx)}

Data Availability Statement

All relevant data are within the manuscript and its Supporting Information files.

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PERMALINK

Trends in the prevalence of obesity and estimation of the direct health costs attributable to child and adolescent obesity in Brazil from 2013 to 2022

Eduardo Augusto Fernandes Nilson

Michele Gonçalves da Costa

Ana Carolina Rocha de Oliveira

Olivia Souza Honorio

Raphael Barreto da Conceição Barbosa

Roles

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Methods

Trends in child obesity

Cost analysis

Table 1. Data inputs for the estimation of time trends in childhood and adolescent obesity and of its direct healthcare costs.

Sensitivity analysis

Results

Table 2. Childhood and adolescent obesity trends in Brazil from 2013 to 2022, by age-group.

Table 3. Total number and costs of hospitalizations with obesity as a primary cause in the Brazilian National Health System (SUS) (Int$), Brazil 2013–2022.

Table 4. Total costs and estimated attributable costs to obesity of hospitalizations in the Brazilian National Health System (SUS) among children and adolescents (Int$), Brazil 2013–2020.

Table 5. Estimated non-hospital, outpatient and medication costs of children and adolescents with obesity, Brazil 2013–2020.

Table 6. Estimated additional non-hospital, outpatient and medication costs of children and adolescents with obesity for families and the Brazilian National Health System (SUS), Brazil 2013–2020 (average and 95% Confidence Intervals).

Discussion

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Alanna Gomes da Silva

Roles

Author response to Decision Letter 0

Decision Letter 1

Alanna Gomes da Silva

Roles

Author response to Decision Letter 1

Decision Letter 2

Alanna Gomes da Silva

Roles

Acceptance letter

Alanna Gomes da Silva

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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