Assessment of Body Mass Index for Obesity Diagnosis in the Mexican Population: A Cross-Sectional Analysis

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript addresses a topic of clinical and epidemiological relevance, evaluating the accuracy of BMI ≥30 for the diagnosis of obesity in the Mexican population and proposing a new cut-off of 27. The study is well conducted, with a large sample and appropriate statistical analysis. The results are consistent with those obtained in other non-Caucasian populations and emphasise the importance of ethnicity-adapted diagnostic criteria. However, the use of bioimpedance analysis as a diagnostic reference is improperly referred to as the ‘gold standard’, when in fact the reference method for assessing body composition is DEXA. It is suggested to correct this definition and to discuss the limitations of BIA, such as the influence of hydration status and individual variability. Furthermore, the selection of the sample, which includes subjects from an obesity clinic and healthcare professionals, results in an obesity prevalence of 68%, well above that of the general population, limiting the transferability of the results. The absence of age-stratified analyses, which is a relevant factor for body composition, should also be better investigated. Finally, the inclusion of clinical data on possible comorbidities could have strengthened the proposal of a new cut-off, demonstrating not only its statistical validity but also its clinical usefulness. Despite these limitations, the work represents a valuable contribution to the discussion on the appropriateness of diagnostic criteria for obesity in the Latin American population.

Author Response

Response to Reviewer 1 Comments

Summary: Thank you very much for taking the time to review this manuscript. We greatly appreciate your constructive feedback. Please find our detailed responses below, along with the corresponding revisions highlighted in track changes in the re-submitted files.

Comment 1: "The manuscript addresses a topic of clinical and epidemiological relevance, evaluating the accuracy of BMI ≥30 for the diagnosis of obesity in the Mexican population and proposing a new cut-off of 27. The study is well conducted, with a large sample and appropriate statistical analysis. The results are consistent with those obtained in other non-Caucasian populations and emphasise the importance of ethnicity-adapted diagnostic criteria."

Response 1: Thank you for your positive feedback. We appreciate your recognition of the clinical and epidemiological relevance of the study. We have carefully considered your suggestions for further refinement.

Comment 2: "However, the use of bioimpedance analysis as a diagnostic reference is improperly referred to as the ‘gold standard’, when in fact the reference method for assessing body composition is DEXA. It is suggested to correct this definition and to discuss the limitations of BIA, such as the influence of hydration status and individual variability."
Response 2: Thank you for pointing this out. We agree with your suggestion and have corrected the description of bioimpedance analysis. We have removed the reference to BIA as the 'gold standard' and acknowledged that DEXA is generally considered the reference method for body composition analysis. Additionally, we have included a discussion on the limitations of BIA, particularly its sensitivity to hydration status and individual variability. The updated text can be found in the

 "Introduccion" section, pages 2, paragraph 4, lines 72-78
" There are various methods for assessing body composition, each with its own accuracy and feasibility. While dual-energy X-ray absorptiometry (DEXA) is considered the gold standard, bioelectrical impedance analysis (BIA) offers a more accessible and practical alternative, particularly in resource-constrained settings. Studies show a strong correlation between BIA and DEXA (r = 0.89, 95% CI: 0.74-0.95), suggesting that BIA can be a valid reference when DEXA is unavailable [9-10]. However, factors like hydration status can influence BIA's accuracy. [11]"

"Introduccion" section, Page 3, paragraph 2, lines 90-94

“The present study aims to evaluate the diagnostic performance of BMI in the Mexican population, comparing it with BIA, which was used as the reference method due to its accessibility and feasibility in clinical practice. By doing so, this study could provide critical insights to optimize obesity diagnostic methods, ultimately contributing to improved prevention and treatment strategies in public health.”
"Discussion" section, Page 9, paragraph 4, lines 342-345

“Despite its accessibility and usefulness, the accuracy of BIA is susceptible to factors such as hydration. However, its strong correlation with the DEXA method (r = 0.89) supports its validity as a diagnostic tool, particularly in settings with limited resources. [21]”

Comment 3: "Furthermore, the selection of the sample, which includes subjects from an obesity clinic and healthcare professionals, results in an obesity prevalence of 68%, well above that of the general population, limiting the transferability of the results."
Response 3: We acknowledge that the selection of the sample may restrict the generalizability of the results. However, we believe that the inclusion of individuals from an obesity clinic and healthcare professionals enabled a comprehensive evaluation of the proposed BMI cutoff in a population with a higher prevalence of obesity.

A statistical analysis was conducted to examine the differences in prevalence across the various methods and cut-off points that were employed. In addition, we employed a Bayesian analysis to adjust the diagnostic parameters influenced by the prevalence of the condition (predictive values).

We have addressed this limitation in the discussion section, highlighting the need for future studies in more representative samples.

"Results" section, page 7, paragraph 1, lines 245-260

“3.3.2 Comparison of prevalences according to the methods used. 

According to the results of the ENSANUT, the prevalence of obesity (BMI ≥30) in the Mexican population is 37.1%. The following prevalences were obtained in our study:  The BMI ≥30 category had a prevalence of 42.5%, the BIA category had a prevalence of 68.1%, and the BMI ≥27 category had a prevalence of 60.9%. The Z-test for difference of proportions yielded the following result:

ENSANUT vs IMC30 from our study: Z=2.96 p= 0.0031

ENSANUT vs BIA:  Z ≈ 16.92 p < 0.0001

IMC30 vs BIA: Z= -9.74 p < 0.0001

IMC27 vs IMC30: Z = -6.96 p < 0.0001 

IMC27 vs BIA: -2.84 p= 0.0044

3.3.3 Correction of predictive values to prevalence according to ENSANUT

When correcting the predictive values for the prevalence in Mexico, the following values were obtained: BMI≥30 PPV: 85.7% [95% CI 81.5,88.9], NPV: 80.9% [95% CI 78.0,82.9] while with BMI≥27 the PPV was 73.4% [95% CI 70.2,76.2] and the NPV was 88.2% [95% CI 85.3,90.5].”

"Discussion" section, page 9, paragraph 4, lines 332- 337

“The prevalence of the disease, utilizing the same cut-off point reported in ENSANUT, was higher in our sample. This phenomenon is hypothesized to be a consequence of the selection of patients in a concentration center, specifically in an obesity care clinic. However, when the data were corrected by Bayesian analysis towards the population prevalence in Mexico, the predictive values maintained a favorable trend with the new cutoff point, especially in terms of NPV, which supports the internal validity of the results.”

"Discussion" section, page 10, paragraph 2, lines 356-361

“Despite the fact that the prevalence of obesity in the study population exceeded that of the general population, this did not affect the sensitivity, specificity, or likelihood ratios of the study. Consequently, the findings can be adapted to regional prevalences, allowing the use of predictive values that are beneficial in clinical practice. Another point of strength was the evaluation of BMI by sex, although a slight discrepancy was observed.”
Comment 4: "The absence of age-stratified analyses, which is a relevant factor for body composition, should also be better investigated."
Response 4: Thank you for this valuable suggestion. We agree that age is a relevant factor in body composition. While we did not conduct age-stratified analyses in this study, we have added a discussion on the potential influence of age on body composition and the need for age-stratified analyses in future research. The updated text can be found in the "Discussion" section, page 9, paragraph 3."325-327"

“The present study is not without its limitations. First, the sample was heterogeneous in terms of age, which prevented a detailed analysis of BMI cut-off points in different age groups.”

"Discussion" section, page 10, paragraph 3. Lines"366-369"

“It is imperative to validate the BMI threshold of ≥27 in more diverse and representative samples of the Mexican population, taking into account variations in age, ethnicity, socioeconomic status, and lifestyle habits to ensure its applicability”

Comment 5: "Finally, the inclusion of clinical data on possible comorbidities could have strengthened the proposal of a new cut-off, demonstrating not only its statistical validity but also its clinical usefulness."
Response 5: We appreciate your suggestion to include clinical data on comorbidities. Although we did not collect detailed data on comorbidities in this study, we acknowledge that this could have strengthened our argument for the clinical relevance of the new BMI cut-off. We have included a statement in the discussion section recommending that future studies explore the relationship between BMI, bioimpedance, and comorbidities in a clinical context. This can be found in the "Discussion" section, page 9, paragraph 3. Lines “325-331”
“The present study is not without its limitations. First, the sample was heterogeneous in terms of age, which prevented a detailed analysis of BMI cut-off points in different age groups. Additionally, the absence of an evaluation of pertinent comorbidities, including but not limited to diabetes and hypertension, hinders a comprehensive understanding of the risks associated with excess adiposity. The absence of adjustments for factors such as socioeconomic status and physical activity also reduces the generalizability of the results, emphasizing the need to validate the BMI ≥27 threshold in more representative samples.”

"Discussion" section, page 10 paragraph 3, Lines “363-364”

“It is recommended that future studies include a more detailed evaluation of comorbidities in the populations analyzed.”

4. Additional clarifications: Below, I have included the specific lines where improvements were made based on the reviewers' contributions. We are extremely grateful for this collaborative effort and hope the final version meets your expectations for prompt publication. Greetings from Mexico!

Introduction provide sufficient background and include all relevant references?	Can be improved:       "Introduccion" section, page 2, paragraph 1. Lines “45-47”   "Introduccion" section, page 2, paragraph 2. Lines “ 48-54”   "Introduccion" section, page 2, paragraph 3. Lines “ 65-71”   "Introduccion" section, page 2, paragraph 4. Lines “ 72-78”   "Introduccion" section, page 2, paragraph 5. Lines “ 79-84”   "Introduccion" section, page 3, paragraph 1. Lines “ 85-89”   "Introduccion" section, page 3, paragraph 2. Lines “ 90-94”
Is the research design appropriate?	Must be improved   " Materials and Methods, 2.1. Study Design, section, page 3, paragraph 3. Lines “ 97-102”
Are the methods adequately described?	Must be improved   " Materials and Methods, section, page 3, paragraph 4. Lines “ 104-126” " Materials and Methods, section, page 4, paragraph 4. Lines “ 141-146”   " Materials and Methods, section, page 4, paragraph 7. Lines “ 159-202”
Are the results clearly presented?	Must be improved " Results” section, page 6, paragraph 1. Lines “210”   " Results” section, page 6, paragraph 2. Lines “220-221”   " Results” section, page 6, paragraph 5. Lines “238-253”   " Results” section, page 7, Tabla 2. Lines “243-244”   " Results” section, page 7, paragraph 1. Lines “245-260”
Are the conclusions supported by the results?	Can be improved   " Conclusions” section, page 10, paragraph 4. Lines “373-379”

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Expert Review of the article entitled: "Assessment of Body Mass Index for Obesity Diagnosis in the Mexican Population: A Cross-Sectional Analysis"

The submitted manuscript addresses a significant clinical and epidemiological issue—the diagnostic accuracy of Body Mass Index (BMI) for identifying obesity within the Mexican population. The study appropriately compares the commonly used BMI criteria with electrical bioimpedance as the reference method. The need for population-specific BMI thresholds justifies the topic selection, the high prevalence of obesity, and its related health consequences in Mexico.

The manuscript is structurally sound and clearly articulates its objectives and hypotheses. The introduction adequately contextualizes the problem and references current international standards and guidelines. However, the authors could better emphasize the clinical and epidemiological significance of the topic within the context of Mexico.

The method description is mainly adequate, but there is an essential limitation that should be explicitly recognized: the study sample includes a heterogeneous mix of patients from an obesity clinic and hospital personnel. Such participant selection could have introduced selection bias and led to overestimating obesity prevalence, consequently impacting diagnostic accuracy metrics. The authors should clearly outline their recruitment procedures and emphasize potential selection bias as an explicit limitation.

A notable strength of the paper is its robust statistical methodology, particularly the appropriate use of ROC curves, sensitivity, specificity, predictive values, likelihood ratios, and Cohen's kappa coefficient. The analysis stratified by sex also adds value, although further clinical interpretation of observed gender differences would strengthen the discussion.

The results are presented clearly, demonstrating convincingly that the conventional BMI≥30 threshold is insufficiently sensitive for diagnosing obesity in the Mexican population. The suggested alternative cutoff of BMI≥27 shows better diagnostic accuracy. Nonetheless, the authors should explicitly address the potential clinical and healthcare implications of lowering the diagnostic threshold, including possible increases in healthcare utilization due to diagnosing more individuals as obese.

In the discussion, the authors adequately refer to relevant international and regional literature advocating for tailored BMI cutoffs across populations. However, they insufficiently address potential confounders affecting their results, such as differences in physical activity, age distribution, or socioeconomic status among participants. Future research directions should be explicitly stated, such as validating the new cutoff in more representative and diverse samples across Mexico.

Conclusions align with the study’s stated aims; however, the authors should more explicitly discuss clinical implications, especially regarding implementing the proposed lower BMI cutoff in daily clinical practice, prevention, and early management of obesity.

The authors should clearly state the following key limitations: Sample heterogeneity possibly influences diagnostic accuracy estimates due to selection bias; there is a lack of sensitivity analysis regarding age and comorbid health status; and there is insufficient discussion of the practical implications of lowering the BMI cutoff.

Therefore, I recommend the following substantial revisions before acceptance for publication:

1. Clearly describe recruitment methods and discuss the impact of potential selection biases explicitly.

2. Expand the discussion to include practical and clinical implications of implementing the proposed BMI cutoff.

3. Clarify the clinical and public-health relevance of the study findings in the conclusions.

4. Explicitly indicate directions for future research, particularly validation studies in broader, more representative Mexican population samples, including various age groups and socioeconomic strata.

5. Consider potential economic and logistical impacts associated with changing the BMI diagnostic threshold.

If these revisions are adequately addressed, the manuscript may be reconsidered for publication. In its current form, significant amendments and enhancements are necessary before acceptance can be recommended.

Author Response

Response to Reviewer 2 Comments

 Summary: Thank you very much for taking the time to review this manuscript. We greatly appreciate your constructive feedback. Please find our detailed responses below, along with the corresponding revisions highlighted in track changes in the re-submitted files.

Comment 1: " The manuscript is structurally sound and clearly articulates its objectives and hypotheses. The introduction adequately contextualizes the problem and references current international standards and guidelines. However, the authors could better emphasize the clinical and epidemiological significance of the topic within the context of Mexico.”

Response 1: Thank you for this suggestion. We agree that reinforcing the national relevance of the study strengthens its justification. Accordingly, we have revised the Introduction to emphasize the specific epidemiological burden of obesity in Mexico, including its impact on morbidity, mortality, and healthcare costs. This contextualization now better frames the need for a population-specific diagnostic approach.

"Introduccion" section, pages 2, paragraph 1, lines 45-53

“According to the 2023 National Health and Nutrition Survey (ENSANUT), 37.1% of Mexican adults aged 20 and older were classified as obese, based on a body mass index (BMI) cutoff of ≥30. [2]

Projections suggest that global obesity levels will increase by more than 50% by 2035, underscoring the urgent need for effective prevention and early detection strategies [3-4]. This emphasizes the necessity for the development and implementation of effective primary prevention and early detection strategies. These efforts must prioritize the patient, incorporating individualized diagnostic criteria, with particular attention to ethnic variations, to enhance prevention and treatment outcomes.[5]”

"Introduccion" section, pages 2, paragraph 3, lines 65-67

“In Mexico, the traditional BMI threshold of ≥30 may not accurately reflect obesity prevalence, as body composition may vary according to ethnicity and other demographic factors.[10]”

"Introduccion" section, pages 3, paragraph 1, lines 85-89

“The WOF estimates that the economic burden of overweight and obesity in Mexico is 23.17 billion dollars, considering both direct and indirect costs. [16] Projections suggest that by 2050, Mexico's gross domestic product could decrease by 5.3%, and health expenditures may increase by 8.9% due to the impact of obesity and related diseases. [17] Additionally, life expectancy in Mexico is expected to decrease by up to 4.2 years by 2050. [18]”

 

Comment 2: " The method description is mainly adequate, but there is an essential limitation that should be explicitly recognized: the study sample includes a heterogeneous mix of patients from an obesity clinic and hospital personnel. Such participant selection could have introduced selection bias and led to overestimating obesity prevalence, consequently impacting diagnostic accuracy metrics. The authors should clearly outline their recruitment procedures and emphasize potential selection bias as an explicit limitation." AND “The authors should clearly state the following key limitations: Sample heterogeneity possibly influences diagnostic accuracy estimates due to selection bias;” AND “Clearly describe recruitment methods and discuss the impact of potential selection biases explicitly.”

Response 2: We appreciate this observation and have made clarifications in the Methods and Discussion sections. We have clearly explained the recruitment procedures and explicitly recognized the possible selection bias resulting from the mixed sample. In addition, we emphasize that the adjusted predictive values were estimated by Bayesian correction based on national obesity prevalence data. Emphasizing that the sensitivity and specificity of diagnostic tests are not affected by the prevalence of the disease.

"Materials and Methods  " section, page 3, paragraph 4, lines 104-114

“A convenience sampling method was employed to recruit participants from two primary sources: the obesity and overweight clinic and employees from the Spanish Hospital. The clinic was specifically chosen due to its focus on obesity management.

A total of 715 Mexican adults were included in the study, recruited between July 1, 2022, and July 30, 2022. Of these, 398 participants were personnel working at the Spanish Hospital of Mexico, and 317 were patients from the Obesity Clinic.

Inclusion criteria included: adults aged 18 years or older, Mexicans, voluntary consent to participate in the study, and willingness to undergo body composition measurements.

Exclusion criteria included: presence of pacemakers, orthoses, prostheses, metallic implants, or any other devices that might interfere with BIA measurements, history of amputation, dehydration, edema, tumors, and pregnant or breastfeeding women.”

"Results" section, page 7, paragraph 1, lines 245-260

“3.3.2 Comparison of prevalences according to the methods used. 

According to the results of the ENSANUT, the prevalence of obesity (BMI ≥30) in the Mexican population is 37.1%. The following prevalences were obtained in our study:  The BMI ≥30 category had a prevalence of 42.5%, the BIA category had a prevalence of 68.1%, and the BMI ≥27 category had a prevalence of 60.9%. The Z-test for difference of proportions yielded the following result:

ENSANUT vs IMC30 from our study: Z=2.96 p= 0.0031

ENSANUT vs BIA:  Z ≈ 16.92 p < 0.0001

IMC30 vs BIA: Z= -9.74 p < 0.0001

IMC27 vs IMC30: Z = -6.96 p < 0.0001 

IMC27 vs BIA: -2.84 p= 0.0044

3.3.3 Correction of predictive values to prevalence according to ENSANUT

When correcting the predictive values for the prevalence in Mexico, the following values were obtained: BMI≥30 PPV: 85.7% [95% CI 81.5,88.9], NPV: 80.9% [95% CI 78.0,82.9] while with BMI≥27 the PPV was 73.4% [95% CI 70.2,76.2] and the NPV was 88.2% [95% CI 85.3,90.5].”

"Discussion" section, page 9, paragraph 4, lines 332- 337

“The prevalence of the disease, utilizing the same cut-off point reported in ENSANUT, was higher in our sample. This phenomenon is hypothesized to be a consequence of the selection of patients in a concentration center, specifically in an obesity care clinic. However, when the data were corrected by Bayesian analysis towards the population prevalence in Mexico, the predictive values maintained a favorable trend with the new cutoff point, especially in terms of NPV, which supports the internal validity of the results.”

"Discussion" section, page 10, paragraph 2, lines 356-361

“Despite the fact that the prevalence of obesity in the study population exceeded that of the general population, this did not affect the sensitivity, specificity, or likelihood ratios of the study. Consequently, the findings can be adapted to regional prevalences, allowing the use of predictive values that are beneficial in clinical practice. Another point of strength was the evaluation of BMI by sex, although a slight discrepancy was observed.”

Comment 3: "A notable strength of the paper is its robust statistical methodology, particularly the appropriate use of ROC curves, sensitivity, specificity, predictive values, likelihood ratios, and Cohen's kappa coefficient. The analysis stratified by sex also adds value, although further clinical interpretation of observed gender differences would strengthen the discussion."
Response 3: We sincerely thank the editor for recognizing the strength of our statistical methodology. We appreciate the suggestion to provide a more detailed clinical interpretation of the observed gender differences. In response, we have expanded the discussion to delve into potential clinical factors that may contribute to the differences observed between sexes, such as biological, social, and behavioral variables.

"Discussion" section, page 9, paragraph 4, lines 339-342

“Additionally, a discrepancy in diagnostic accuracy between male and female subjects was identified, indicating the possible need to adapt BMI thresholds according to gender. This observation necessitates further validation through population-based epidemiological studies.” 

"Discussion" section, page 10, paragraph 2, lines 360- 371

“Another point of strength was the evaluation of BMI by sex, although a slight discrepancy was observed. To ensure epidemiological and pragmatic convenience, BMI for both sexes was equated to 27.

It is recommended that future studies include a more detailed evaluation of comorbidities in the populations analyzed. This will facilitate the enhancement of diagnostic methodologies and the customization of preventive and therapeutic approaches, particularly in contexts characterized by high obesity prevalence.  It is imperative to validate the BMI threshold of ≥27 in more diverse and representative samples of the Mexican population, considering variations in age, ethnicity, socioeconomic status, and lifestyle habits to ensure its applicability. Furthermore, analysis models must be adjusted to account for confounding factors, such as physical activity and age distribution, which could have influenced the results and the accuracy of the diagnosis.”

Comment 4: " The results are presented clearly, demonstrating convincingly that the conventional BMI≥30 threshold is insufficiently sensitive for diagnosing obesity in the Mexican population. The suggested alternative cutoff of BMI≥27 shows better diagnostic accuracy. Nonetheless, the authors should explicitly address the potential clinical and healthcare implications of lowering the diagnostic threshold, including possible increases in healthcare utilization due to diagnosing more individuals as obese.” AND “and there is insufficient discussion of the practical implications of lowering the BMI cutoff.” AND “Expand the discussion to include practical and clinical implications of implementing the proposed BMI cutoff.” AND “Consider potential economic and logistical impacts associated with changing the BMI diagnostic threshold.”
Response 4: We greatly appreciate the editor's feedback. In response to the suggestion, we have expanded the discussion to explicitly address the clinical and healthcare implications of lowering the diagnostic threshold to BMI≥27. Specifically, we highlight the potential for increased healthcare utilization due to the identification of a larger number of individuals as obese. This could lead to greater demands on healthcare services, including preventive care, diagnostic testing, and management strategies. However, we also emphasize that early identification of obesity can potentially lead to more timely interventions and improvements in long-term health outcomes, which may offset the short-term increase in healthcare utilization.

" Introduction " section, page 3, paragraph 1."85-94"

“The WOF estimates that the economic burden of overweight and obesity in Mexico is 23.17 billion dollars, considering both direct and indirect costs. [16] Projections suggest that by 2050, Mexico's gross domestic product could decrease by 5.3%, and health expenditures may increase by 8.9% due to the impact of obesity and related diseases. [17] Additionally, life expectancy in Mexico is expected to decrease by up to 4.2 years by 2050. [18]

The present study aims to evaluate the diagnostic performance of BMI in the Mexican population, comparing it with BIA, which was used as the reference method due to its accessibility and feasibility in clinical practice. By doing so, this study could provide critical insights to optimize obesity diagnostic methods, ultimately contributing to improved prevention and treatment strategies in public health.”

"Discussion" section, page 9, paragraph 1."303-324"

“According to studies on health policy conducted by the Organization for Economic Cooperation and Development (OECD), the prevalence of overweight, obesity, and related diseases is projected to result in a decline in life expectancy by an average of 2.7 years over the ensuing 25-year period within the member countries of the OECD. For instance, in Mexico, the anticipated reduction in life expectancy is estimated to be 4.2 years. [3-4] This underscores the pressing need for the timely and precise diagnosis of these conditions, underscoring the imperative for the adoption of a primary prevention model. One potential solution to this problem is to lower the BMI threshold to ≥27, which has been shown to improve the detection of obesity and allow for more timely interventions in at-risk individuals, without the need to implement other techniques in mass screening tests.

The implementation of such a strategy would facilitate the development of more effective preventive measures, thereby contributing to a reduction in the economic burden of obesity in Mexico. This burden is currently estimated at US$23.17 billion, encompassing both direct and indirect healthcare expenditures, including years of life lost and premature mortality from associated diseases. [17] While this adjustment increases the number of patients classified as obese, in the long term it could generate significant savings. A primary prevention approach, centered on the timely detection and management of obesity in its nascent stages, holds considerable potential in averting chronic diseases such as type 2 diabetes and cardiovascular disease. This, in turn, would contribute to a reduction in healthcare expenditures and a corresponding alleviation of the healthcare system's burden.”

Comment 5: “In the discussion, the authors adequately refer to relevant international and regional literature advocating for tailored BMI cutoffs across populations. However, they insufficiently address potential confounders affecting their results, such as differences in physical activity, age distribution, or socioeconomic status among participants. Future research directions should be explicitly stated, such as validating the new cutoff in more representative and diverse samples across Mexico.” AND “there is a lack of sensitivity analysis regarding age and comorbid health status;” AND “Explicitly indicate directions for future research, particularly validation studies in broader, more representative Mexican population samples, including various age groups and socioeconomic strata.”

Response 5: We appreciate the editor's constructive feedback. In response to the comment, we have expanded the discussion to address the potential confounders that may have influenced the results of our study, including differences in physical activity, age distribution, and socioeconomic status among participants. We recognize that these factors may contribute to variability in body composition and could affect the generalizability of our findings.

"Discussion" section, page 10 paragraph 3, Lines “363-371”

“It is recommended that future studies include a more detailed evaluation of comorbidities in the populations analyzed. This will facilitate the enhancement of diagnostic methodologies and the customization of preventive and therapeutic approaches, particularly in contexts characterized by high obesity prevalence.  It is imperative to validate the BMI threshold of ≥27 in more diverse and representative samples of the Mexican population, considering variations in age, ethnicity, socioeconomic status, and lifestyle habits to ensure its applicability. Furthermore, analysis models must be adjusted to account for confounding factors, such as physical activity and age distribution, which could have influenced the results and the accuracy of the diagnosis.”

Comment 6:“Conclusions align with the study’s stated aims; however, the authors should more explicitly discuss clinical implications, especially regarding implementing the proposed lower BMI cutoff in daily clinical practice, prevention, and early management of obesity.” AND “Clarify the clinical and public-health relevance of the study findings in the conclusions”

Response 6: We appreciate the editor's feedback regarding the need for a more explicit discussion of the clinical implications of implementing the proposed lower BMI cutoff. In response, we have expanded the Conclusion section to address the potential impact of the proposed BMI≥27 threshold on daily clinical practice, as well as its implications for obesity prevention and early management.

" Conclusions " section, page 10 paragraph 4, Lines “373-379”

“Adopting a BMI cutoff of ≥27 kg/m² improves sensitivity, reduces false negatives, and better reflects obesity prevalence in the Mexican population. Given the simplicity, scalability, and affordability of interventions like diet and exercise, implementing this change could enhance obesity prevention and improve health outcomes on a national scale. Future studies should validate these findings in more representative and diverse populations, incorporating comorbidities, socioeconomic variables, and lifestyle factors to refine diagnostic tools and guide public health strategies.”

4. Additional clarifications: Below, I have included the specific lines where improvements were made based on the reviewers' contributions. We are extremely grateful for this collaborative effort and hope the final version meets your expectations for prompt publication. Greetings from Mexico!

Introduction provide sufficient background and include all relevant references?	Can be improved:       "Introduccion" section, page 2, paragraph 1. Lines “45-47”   "Introduccion" section, page 2, paragraph 2. Lines “ 48-54”   "Introduccion" section, page 2, paragraph 3. Lines “ 65-71”   "Introduccion" section, page 2, paragraph 4. Lines “ 72-78”   "Introduccion" section, page 2, paragraph 5. Lines “ 79-84”   "Introduccion" section, page 3, paragraph 1. Lines “ 85-89”   "Introduccion" section, page 3, paragraph 2. Lines “ 90-94”
Is the research design appropriate?	Must be improved   " Materials and Methods, 2.1. Study Design, section, page 3, paragraph 3. Lines “ 97-102”
Are the methods adequately described?	Must be improved   " Materials and Methods, section, page 3, paragraph 4. Lines “ 104-126” " Materials and Methods, section, page 4, paragraph 4. Lines “ 141-146”   " Materials and Methods, section, page 4, paragraph 7. Lines “ 159-202”
Are the results clearly presented?	Must be improved " Results” section, page 6, paragraph 1. Lines “210”   " Results” section, page 6, paragraph 2. Lines “220-221”   " Results” section, page 6, paragraph 5. Lines “238-253”   " Results” section, page 7, paragraph 7. Lines “238-253”   " Results” section, page 7, Tabla 2. Lines “244-245”   " Results” section, page 7, paragraph 1. Lines “246-261”
Are the conclusions supported by the results?	Can be improved   " Conclusions” section, page 10, paragraph 4. Lines “377-386”

 

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The article is very interesting and relevant due to the high prevalence of obesity and associated medical diseases.

The aim of the article was to evaluate the diagnostic efficiency of obesity by BMI ≥ 30 compared to body fat determination using bioimpedance in a cross-sectional, analytical study.

The article requires correction.

My comments:

1. Inaccuracy in line 142. The word "Table 1" should be moved to line 141, since the table does not contain data that the prevalence of obesity is 68%.
2. In the Abstract (line 22), as well as in Section 3.1. (line 135) it is indicated that there were 715 examined individuals. The data in Table 1 were obtained from 715 people. However, further, in Section 3.2. (line 152) it is indicated that the bioimpedance method was used to estimate body fat % only in 487 people. The purpose of the study was to compare the results of the two methods. So the comparison was only for 487 people, not 715? Why? Everything needs to be recalculated and the results rewritten.
3. Some sentences in the text are written unclearly, completely unclearly. There are several of them. For example, the sentence on line 153-154. How did the authors get the numbers and what are these numbers? Correction needs to be made. And so on throughout the text.

Author Response

Response to Reviewer 3 Comments

Summary: Thank you very much for taking the time to review this manuscript. We greatly appreciate your constructive feedback. Please find our detailed responses below, along with the corresponding revisions highlighted in track changes in the re-submitted files.

Comment 1: " Inaccuracy in line 142. The word "Table 1" should be moved to line 141, since the table does not contain data that the prevalence of obesity is 68%."

Response 1: Thank you for pointing this out. We have corrected the inaccuracy and moved the reference to "Table 1" , as the table does not contain data stating that the prevalence of obesity is 68%. The text has been revised accordingly for clarity.

The updated text can be found in the "Results" section, page 10, paragraph 2, Table 1 Descriptive statistics, lines 211.

Comment 2: " In the Abstract (line 22), as well as in Section 3.1. (line 135) it is indicated that there were 715 examined individuals. The data in Table 1 were obtained from 715 people. However, further, in Section 3.2. (line 152) it is indicated that the bioimpedance method was used to estimate body fat % only in 487 people. The purpose of the study was to compare the results of the two methods. So the comparison was only for 487 people, not 715? Why? Everything needs to be recalculated and the results rewritten."

 

Response 2: Thank you for pointing out the apparent discrepancy regarding the number of participants. We would like to clarify that the study indeed included a total of 715 participants, as initially stated in both the Abstract and Section 3.1

The confusion arose due to a misinterpretation of the text in Section 3.2, where it was mentioned that bioimpedance analysis was performed on a subset of 487 individuals. This was a misunderstanding in the phrasing and not a reflection of the study design. All 715 participants underwent the necessary measurements, including BMI and bioimpedance, and no recalculations or changes in the sample size are needed.

We have revised the manuscript for clarity to ensure consistency in the presentation of the sample size across all sections and to avoid any further confusion.

We appreciate your careful review and the opportunity to clarify this matter

 "Results" section, pages 5, paragraph 2, lines 220-221
"The reference test (BIA) diagnosed obesity in 487 (68.1%) of the 715 individuals. While BMI≥30 diagnosed obesity in 304 (42.5%) of the 715 individuals.”

Comment 3: " Some sentences in the text are written unclearly, completely unclearly. There are several of them. For example, the sentence on line 153-154. How did the authors get the numbers and what are these numbers? Correction needs to be made. And so on throughout the text."
Response 3: Thank you for pointing out the unclear phrasing in lines 153-154. We understand that the wording may have caused confusion. To clarify:

The reference test (bioimpedance) was used to diagnose obesity in 487 individuals, representing 68.1% of the total sample of 715 participants. On the other hand, using the BMI ≥ 30 threshold, obesity was diagnosed in 304 individuals (42.5%) of the same 715 participants. The comparison of obesity diagnosis proportions between the two methods (bioimpedance and BMI) yielded a p-value of 0.004, as determined by the Chi-square test.

We have revised the manuscript to make these distinctions clearer, ensuring that the relationship between the two diagnostic methods is transparent and easy to follow. Thank you once again for your valuable feedback.

Results" section, pages 5, paragraph 2, lines 220-223
“The reference test (BIA) diagnosed obesity in 487 (68.1%) of the 715 individuals. While BMI≥30 diagnosed obesity in 304 (42.5%) of the 715 individuals. The comparison of proportions of obesity diagnosis with these two methods yielded a p-value of 0.004 using the Chi-square test.”
4. Additional clarifications: Additionally, we would like to confirm that, after revising the manuscript as requested, everything is now accurate, and no recalculation or rewriting of the results is necessary.

Below, I have included the specific lines where improvements were made based on the reviewers' contributions. We are extremely grateful for this collaborative effort and hope the final version meets your expectations for prompt publication. Greetings from Mexico!

Introduction provide sufficient background and include all relevant references?	Can be improved:       "Introduccion" section, page 2, paragraph 1. Lines “45-47”   "Introduccion" section, page 2, paragraph 2. Lines “ 48-54”   "Introduccion" section, page 2, paragraph 3. Lines “ 65-71”   "Introduccion" section, page 2, paragraph 4. Lines “ 72-78”   "Introduccion" section, page 2, paragraph 5. Lines “ 79-84”   "Introduccion" section, page 3, paragraph 1. Lines “ 85-89”   "Introduccion" section, page 3, paragraph 2. Lines “ 90-94”
Is the research design appropriate?	Must be improved   " Materials and Methods, 2.1. Study Design, section, page 3, paragraph 3. Lines “ 97-102”
Are the methods adequately described?	Can be improved " Materials and Methods, section, page 3, paragraph 4. Lines “ 104-126” " Materials and Methods, section, page 4, paragraph 4. Lines “ 141-146”   " Materials and Methods, section, page 4, paragraph 7. Lines “ 159-202”
Are the results clearly presented?	Must be improved " Results” section, page 6, paragraph 1. Lines “210”   " Results” section, page 6, paragraph 2. Lines “220-221”   " Results” section, page 6, paragraph 5. Lines “238-253”   " Results” section, page 7, Tabla 2. Lines “243-244”   " Results” section, page 7, paragraph 1. Lines “245-260”
Are the conclusions supported by the results?	Must be improved   " Conclusions” section, page 10, paragraph 4. Lines “373-379”

 

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have addressed all my concerns

Reviewer 2 Report

Comments and Suggestions for Authors

The revisions made to the manuscript by the authors are satisfactory to me.

Reviewer 3 Report

Comments and Suggestions for Authors

The authors have done a great job of correcting the article.

The article has become much better.

I have no more comments.