CHOICES National Action Kit 2.0: User Guide, Version 1.1 [Last updated 4/3/2024]
About
The CHOICES National Action Kit provides a menu of strategies with good evidence that they can reduce excess weight gain, improve nutrition and/or physical activity environments, and promote related health behaviors. The CHOICES team has projected the national population reach, impact on health, implementation costs, health care cost savings, and health equity (when relevant data are available) for effective policies and programs that can be used in schools, early care and education and out-of-school settings, communities, and clinics. The kit allows you to compare up to four strategies at a time to help inform your organization’s decision-making around promoting healthy weight. Learn more about our methods.
Individuals whose work focuses on promoting healthy weight, healthy eating, and active living in the United States can use the kit to:
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- Compare strategies to understand differences among them in the numbers of people they reach, implementation costs, impact on health, cost-effectiveness, and health equity (when relevant data are available)
- Compare strategies that influence key health behaviors (like reducing sugary drink consumption) or by age group within a given setting or across settings.
- Understand implementation considerations for each strategy (e.g., the potential policy mechanisms that could be used or the activities and resources that are required for implementation)
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Information & Frequently Asked Questions
Background Information
Why does CHOICES use BMI as a population health indicator?
Why does CHOICES focus on children?
Methods
How did CHOICES choose these strategies?
How does CHOICES project impacts of strategies on population health?
How does CHOICES project impacts of strategies on health disparities and equity?
What is not included in the CHOICES model?
Results
What metrics does CHOICES report and what do they mean?
How do I interpret modeling projections?
What are uncertainty intervals?
What is needed to implement these strategies?
Who would pay for the implementation of these strategies?
What are QALYs, and why use them to set priorities for strategies to improve health?
How is cost-effectiveness assessed using cost per QALY?
Why are some of the values in the results table noted as “cost-saving”?
How can I share the results of a comparison?
How can I apply national model results to my state or local area?
What other details should I consider when prioritizing strategies to promote healthy weight with decision-makers and key partners?
General
Why does the Action Kit ask for my personal information?
Where can I get more information about using the Action Kit?
Background Information
Why does CHOICES use BMI as a population health indicator?
CHOICES focuses on programs and policies that can help reverse the societal and environmental conditions that drive increases in excess body weight and that emphasize healthy eating, improved physical activity, and reduced screen viewing. CHOICES use the terms “obesity” and “BMI” in certain places throughout our site and our resources when sharing direct findings from our research. Excess body weight is associated with reduced quality of life and increased risk for chronic diseases like diabetes, heart disease, and cancers,1 greater health care expenditures (Ward et al., PloS One, 2021),2 and increased mortality risk (Ward et al., eClinicalMedicine, 2022).3 Obesity is a category of excess weight defined by body mass index (BMI), which is calculated as the ratio of a person’s weight (kg) to their height squared (m2).4 BMI is used to define obesity for adults and children aged 2 years and older. Obesity is a chronic health condition recognized by the National Institutes of Health, the American Medical Association, Medicare, and Medicaid.
BMI is a useful population health indicator, although it does have limitations. BMI has been shown to be a good measure of individual-level adiposity, correlating highly (r=0.8) with gold standard measures of percent body fat, among adults, children and adolescents and for different gender and racial/ethnic groups.5,6 BMI is relatively simple to collect and easy to calculate, and it is used widely in medical and scientific research to measure population health.
However, weight stigma occurs when people are blamed for their weight. Weight stigma can increase a person’s risk of engaging in unhealthy eating behaviors and low levels of physical activity and can reduce both the quality of health care a person receives and their utilization of care, all undermining public health.7 CHOICES evaluates the cost-effectiveness of policies and programs aimed at improving nutrition and physical activity environments, promoting related health behaviors, and promoting a healthy weight across all population groups and BMI levels.
References
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- Centers for Disease Control and Prevention. Overweight & Obesity: Consequences of Obesity. Accessed May 16, 2022. https://www.cdc.gov/obesity/basics/consequences.html.
- Ward ZJ, Bleich SN, Long MW, Gortmaker SL. Association of body mass index with health care expenditures in the United States by age and sex. PLoS ONE. 2021 Mar;16(3): e0247307. doi10.1371/journal.pone.0247307.
- Ward ZJ, Willett WC, Hu FB, Pacheco LS, Long MW, Gortmaker SL. Excess mortality associated with elevated body weight in the USA by state and demographic subgroup: A modelling study. eClinicalMedicine. 2022 Apr;48. doi:10.1016/j.eclinm.2022.101429
- Centers for Disease Control and Prevention. Obesity Basics. Accessed September 13, 2023 at: https://www.cdc.gov/obesity/basics/index.html.
- Woolcott OO, Bergman RN. Relative fat mass (RFM) as a new estimator of whole-body fat percentage ─ A cross-sectional study in American adult individuals. Sci Rep. 2018 Jul 20;8(1):10980.
- Woolcott OO, Bergman RN. Relative Fat Mass as an estimator of whole-body fat percentage among children and adolescents: A cross-sectional study using NHANES. Sci Rep. 2019 Oct 24;9(1):15279.
- Puhl RM, Heuer CA. Obesity stigma: Important considerations for public health. Am J Public Health. 2010;100(6):1019-1028. doi.org/10.2105/AJPH.2009.159491
Why does CHOICES focus on children?
Every child deserves opportunities to grow up at a healthy weight. Having excess weight has clear implications for health and health care costs. According to CHOICES research (Ward et al., N Engl J Med, 2017), more than half of today’s children will have obesity when they are adults. People with obesity are at an increased risk for an array of serious diseases and health conditions, including heart disease, type 2 diabetes, asthma, cancer, and reduced quality of life. Children with obesity are more likely to have obesity when they are adults, so early prevention is key.
A CHOICES study (Ward et al., PLoS ONE, 2021) shows that excess body weight is associated with higher health care costs for people across a wide range of body mass index (BMI) levels in the U.S. Adults with obesity and severe obesity incur on average about $2,000 and $3,000 each year in additional health care costs, respectively. Children with obesity also incur more health care costs than children without obesity (about $100 and $300 annually for children with obesity and severe obesity, respectively).
Methods
How did CHOICES choose these strategies?
The strategies presented in the CHOICES National Action Kit come from a menu of strategies that our team, in consultation with key partners and our expert advisory group, has identified as having high-quality evaluations and strong evidence for effectiveness for
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- reducing excess weight gain and/or
- improving behavioral risk factors for excess weight (such as reduced sugary drink intake, increased physical activity, and/or decreased screen time).
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Some strategies presented in the CHOICES National Action Kit have been implemented nationally. These strategies are included to demonstrate their estimated impact and to inform ongoing or future policy updates.
CHOICES has published cost-effectiveness results for these strategies in peer-reviewed journals (Kenney et al., Pediatrics, 2024; Dupuis et al., Am J Prev Med, 2024; Kenney et al., Child Obes, 2021; Kenney et al., Obesity (Silver Spring), 2019; Sharifi et al., Pediatrics, 2017; Cradock et al.,Prev Med, 2016; Gortmaker et al., Health Aff, 2015). Additional strategies will be added to the kit once CHOICES model results have been published. Learn more about our methods.
How does CHOICES project impacts of strategies on population health?
CHOICES projects the impacts of strategies on population health using a computer model of the U.S. population that projects BMI changes and health outcomes over time. CHOICES uses information on the economic costs and health effects of interventions based on structured reviews of evidence and available data. Learn more about our methods.
How does CHOICES project impacts of strategies on health disparities and equity?
CHOICES projects the impacts of strategies on both overall population health and health equity, when data are available. Learn more about our methods for projecting health equity impacts.
What is not included in the CHOICES model?
The CHOICES team recognizes that many of these strategies will have additional benefits beyond helping individuals achieve a healthy weight. The health behaviors that CHOICES strategies address impact additional outcomes that are important for children’s well-being.
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- Reducing sugary drink consumption can prevent type 2 diabetes (independent of changes in body weight), as well as tooth decay. Learn more about reducing sugary drink consumption.
- Increasing children’s physical activity will likely also have positive benefits related to improved bone health, aerobic and muscular fitness, cognition, and academic performance. Learn more about increasing children’s physical activity.
- Decreasing noneducational screen time can leave more time to develop important skills and can improve adolescents’ social-emotional skills and sleep.
- Increasing water intake is a critical way to ensure proper hydration.
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CHOICES measures changes in these health behaviors. We do not measure changes in outcomes not related to healthy weight because it is beyond the scope of the CHOICES model. CHOICES cost-effectiveness measures can be used along with other key considerations about feasibility and impacts in a local context to prioritize strategies to promote a healthier weight among children.
Results
What metrics does CHOICES report and what do they mean?
CHOICES reports multiple metrics for the available strategies in this tool. See the CHOICES National Action Kit Modeled Outcomes Glossary for a list and description of the metrics reported in this tool. Effects of strategies on health behaviors related to weight are reported when the strategy aims to improve a health behavior and data are available to quantify improvements in health behavior. Health behaviors that some strategies focus on include:
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- Sugary drink intake
- Physical activity
- Time spent watching TV
- Water intake
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How do I interpret modeling projections?
Modeling projections are made for a particular model period. This is the timeframe for which individuals in the model are followed to make projections of future impacts. In the CHOICES model, results are typically estimated for a 10-year period which covers a recent or the current year and projects 10 years into the future.* As new data become available, the model inputs and assumptions may change over time, and new simulations may update the model period to be more relevant for current decision makers. In the past, the CHOICES model was often updated every one to two years to reflect the most recent available data. However, as the COVID-19 pandemic interrupted the data collection activities of various sources that the CHOICES model uses, more recent data are limited. As new data become available in the future, the model will be updated to account for the impact of the pandemic.
*For strategies that have been implemented nationally, results are typically estimated for a 10-year period beginning in the first year the strategy was implemented.
What are uncertainty intervals?
CHOICES reports the mean estimate as well as uncertainty intervals for outcomes to describe both the most likely estimate and the likely range of estimates projected by the model. CHOICES calculates 95% uncertainty intervals by running the model 1,000 times and reporting the range (95% of estimates, centered on the mean) of projected outcomes that account for uncertainty from data sources and population projections. Uncertainty intervals reflect both sampling uncertainty and parameter uncertainty, or uncertainty due to sampling errors and uncertainty of a parameter value due to observed variability and measurement. CHOICES reports uncertainty intervals because they reflect both types of uncertainty and can be used to describe the precision of predicted estimates from simulation models like the CHOICES microsimulation model.
Uncertainty intervals are different than confidence intervals. Confidence intervals have a specific definition in statistics, while uncertainty intervals are a more general concept. Confidence intervals only reflect how sampling uncertainty affects the estimate of a parameter in a statistical model.
References
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- Gelman A, Carlin JB, Stern HS, et al. Bayesian Data Analysis (3rd ed.). Chapman and Hall/CRC; 2013. https://doi.org/10.1201/b16018
- Parmigiani G. Measuring uncertainty in complex decision analysis models. Stat Methods Med Res. 2002 Dec;11(6):513-37. doi: 10.1191/0962280202sm307ra. PMID: 12516987.
- Sculpher MJ, Basu A, Kuntz KM, Meltzer DO. Reflecting Uncertainty in Cost-Effectiveness Analysis. In: Neumann PJ, Sanders GD, Russell LB, Siegel JE, Ganiats TG, editors. Cost-Effectiveness in Health and Medicine. Second. New York, NY: Oxford University Press; 2017. p. 289–318.
What is needed to implement these strategies?
To learn more about the activities, resources, and leadership needed for implementation of each strategy, click “Strategy Report” in the results table and see the section “Strategy Profile”, or click “More Strategy Information” in the results table to be taken directly to the “Strategy Profile”. The strategy profiles have information that could be useful for planning and prioritization purposes.
Projected costs to implement a strategy nationally are reported in the kit by the activity categories listed in the “Strategy Profile”. To see projected costs of a strategy by activity, click the “See Cost Results” link in the results table.
Who would pay for the implementation of these strategies?
To assist in decision-making for the available strategies, CHOICES reports projected costs to implement a strategy nationally by payer. The payer is the entity responsible for each cost. Costs are reported in the kit for the following payers:
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- Federal government
- State government
- Local government
- School district
- School
- Family/individual
- Industry
- Nonprofit
- Health care
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To see projected costs of a strategy by payer, click the “See Cost Results” link in the results table.
What are QALYs, and why use them to set priorities for strategies to improve health?
One of the important consequences of excess weight gain and obesity is reduced quality of life and life expectancy. CHOICES estimates the quality-adjusted life years (QALYs) gained from implementing a strategy as a measure of how much a strategy could improve the quantity and quality of life for a population. QALYs can provide useful information to decision makers when prioritizing scarce resources, since longevity and quality of life are agreed to be valuable health outcomes in society. The strategies evaluated by CHOICES are generally intended to prevent future excess weight gain and obesity, and thus lead to increased QALYs.
A QALY is a measure of both the quantity and quality of life. QALYs measure length of life adjusted for health-related quality of life (HRQoL). HRQoL measures account for health status in multiple domains of physical and psychosocial health and people’s reported preferences for different health states. CHOICES accounts for people’s reported preferences for having health states associated with normal weight, overweight, and obesity. To estimate HRQoL, CHOICES uses results from nationwide surveys in which people report their own health status (or the health of their children), mapped onto societal values of health states from a nationally representative study. For more details on how CHOICES estimates HRQoL measures, see the CHOICES Microsimulation Model Technical Documentation.
References
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- Ward ZJ, Barrett JL, Cradock AL, Dupuis R, Lee MM, Long MW, Musicus AA, Gortmaker SL. Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Microsimulation Model Technical Documentation: Details on Model Parameters (CHOICES v4.6.1). CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; March 2023.
How is cost-effectiveness assessed using cost per QALY?
CHOICES uses cost per quality-adjusted life year (QALY) gained as a cost-effectiveness metric to determine whether a strategy is good value for money. Cost per QALY thresholds are defined to identify whether or not a strategy could be considered cost-effective based on its projected net cost per improvement in population health. Thresholds define how much we are willing to pay as a society for health improvement. Anything that costs less than the threshold could be considered cost-effective. In the US, there is no universal threshold to define cost-effectiveness based on cost per QALY. Estimated thresholds ranging between $50,000 per QALY and $200,000 per QALY are commonly used, with $100,000 per QALY or $150,000 per QALY suggested as options for a single threshold.
CHOICES looks at cost-effectiveness in terms of overall population health outcomes related to excess weight. Cost per QALY related to excess weight outcomes is a useful metric for assessing the cost-effectiveness of implementing a strategy aimed at improving healthy eating and physical activity.
References
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- Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness–the curious resilience of the $50,000-per-QALY threshold. N Engl J Med. 2014 Aug 28;371(9):796-7. doi: 10.1056/NEJMp1405158. PMID: 25162885.
Why are some of the values in the results table noted as “cost-saving”?
CHOICES projects that some policies and programs aimed at improving healthy eating and physical activity are cost-saving. In most cases, a strategy is reported as “cost-saving” because projections show that health care costs saved due to reductions in excess weight would be greater than the implementation costs. Cost-saving interventions are relatively uncommon and hold special interest for decision makers. A cost-saving strategy provides an opportunity to improve health and save money. Exceptions are noted in the footnotes and detailed strategy descriptions that can be accessed by clicking on “More Strategy Information” in the results table.
How can I share the results of a comparison?
You can export your comparison of strategies as a PDF by clicking “Export as PDF” at the top of the results table, or you can click “Print” to print to a printer connected to your computer. You can then either print or electronically share the comparison with others to aid in decision-making related to strategies to promote healthy weight.
How can I apply national model results to my state or local area?
National model results can be used to compare the impacts of strategies and to identify strategies that could be the best value for money in your state or local area. National results do not show how many people could be reached by a strategy in your area alone, and they do not account for potential differences in how a strategy might be implemented in your area. However, comparing national strategy results can inform decision-making in your state or local area. Here are some examples.
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- Compare “Behavioral Change per Person” of multiple strategies to compare change in health behavior and identify strategies that focus on priority health behaviors in your area.
- Compare “Population Reach” of multiple strategies to see which might reach the most people in your area.
- Compare “Obesity Prevented”, “Child Obesity Prevented”, or “Obesity Years Prevented” of multiple strategies to see which might have the biggest impact on levels of excess weight in your area.
- Compare “Cost per Person” of multiple strategies to see which might be the least expensive to implement per person in your area.
- Compare “Health Care Costs Saved per $1 Invested” of multiple strategies to see which might be cost-saving or save the most in future health care costs per dollar invested in your area.
- Compare “Cost per QALY Gained” of multiple strategies to see which might be cost-saving or have the lowest net cost per health improvement in terms of quality-adjusted life years.
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What other details should I consider when prioritizing strategies to promote healthy weight with decision-makers and key partners?
The CHOICES team projects the impacts of strategies on overall population health. In addition to the cost-effectiveness measures described in the CHOICES model, you might also consider:
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- What will interest organizations/people who are part of an area’s efforts to promote healthy weight
- Whether organizations/people who would be implementing a particular strategy can participate in the decision-making process
- Whether those who have the authority to make a change or provide information to inform decision-making are involved in considering the information about a particular strategy
- Whether it would make sense to pair one strategy with another during decision-making – for example, pairing a strategy that has the potential to generate revenue, such as a sugary drink excise tax, with a strategy that requires an investment, such as one in an early care and education setting
- What is the effect of the strategy on health equity?
- How could the strategy improve racial/ethnic and/or socioeconomic health equity in the population?
- Is there equity in access to, or utilization of, the specific strategy? For example, consider whether only individuals with high income will be able to access the strategy.
- How acceptable is the strategy?
- Is the strategy acceptable to the various individuals and groups affected by the strategy (children and adolescents, parents and caregivers, teachers, the general community, third-party funders, health service providers, government, and the private sector)?
- Do key groups that would be implementing the strategy see it positively?
- Are there examples of successful implementation?
- How feasible is the strategy?
- Is there expertise available to support implementing the strategy on a state or local scale?
- How much will the strategy cost, and who will have to pay to implement?
- What is the time scale for implementation?
- How sustainable is the strategy?
- How much ongoing funding support is required?
- How much community empowerment, capacity building, and level of policy support is likely to be achieved?
- What is the likelihood of required changes in behaviors, practices, and attitudes being achieved on an ongoing basis?
- Are there side effects or unintended consequences of the strategy?
- What are the both the positive and negative impacts of this strategy on:
- other health outcomes (e.g., anxiety/depression stemming from stigmatization)?
- environmental outcomes (e.g., less pollution/congestion)?
- other economic consequences (e.g., impact on industry)?
- What are the both the positive and negative impacts of this strategy on:
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Some of our partners have taken steps to implement the strategies that they’ve modeled with us:
General
Why does the Action Kit ask for my personal information?
After you have selected strategies and clicked the “Build Comparison” button, you will be asked to share some information. This helps the CHOICES team know who is using the tool (organization type) and where a user is from (location). The provision of any additional information is optional.
Where can I get more information about using the Action Kit?
Contact the CHOICES team at choicesproject@hsph.harvard.edu with any questions.
Contributors to the CHOICES National Action Kit 2.0
Funding
This work has been supported by grants from The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention, or other funders.