Resource Type: Research Briefs & Reports

Brief: Water Dispensers in Massachusetts Schools

Posted on June 28, 2023

Water fountain and filling station on a wall in a school

The information in this brief is intended only to provide educational information.

This brief summarizes a CHOICES Learning Collaborative Partnership model examining a strategy to improve access to drinking water in schools in Massachusetts. This strategy involves the installation of touchless chilled water dispensers on or near school cafeteria lunch lines in K-8 public schools with adequate plumbing.

The Issue

All students should have access to safe, clean, and appealing drinking water, no matter where they go to school. Yet, nearly half of K-8 public schools in Massachusetts have identified elevated concentrations of lead in their drinking water and need to improve their drinking water infrastructure.¹

Providing access to appealing drinking water gives students a healthier alternative to sugary drinks, like sweetened fruit drinks, sports drinks, and soda. In 2021, most adolescents in Massachusetts reported consuming sugary drinks,² which has been linked to excess weight gain, type 2 diabetes, and heart disease.^3,4 Students drink more water when schools provide access to water at lunch at no charge,⁵ and improving school water access may help kids grow up at a healthy weight.^6,7 Creating a healthy, equitable school environment with appealing drinking water access can help set children up for a healthy future.

About the Water Dispensers in Schools Strategy

This strategy applied an equity lens to increasing water access by installing touchless water dispensers on or near school cafeteria lunch lines in K-8 Massachusetts public schools with identified needs. Priority schools would be those with elevated concentrations of lead in drinking water documented via state lead testing programs¹ and located in cities and towns with Environmental Justice designation based on the community’s share of households with lower incomes, limited English proficiency, or individuals identifying as Black, Indigenous, or people of color.⁸ Better drinking water access in schools has been shown to increase water intake and may help promote a healthy weight.⁶ The Massachusetts Departments of Public Health and Elementary and Secondary Education would provide outreach to school districts to encourage the installation of water dispensers through existing relationships. Putting this strategy into place would require resources for administering the program, installing and maintaining dispensers, utility costs, disposable cup provision, and lead testing and remediation.

Comparing Costs and Outcomes

A CHOICES cost-effectiveness analysis compared the costs and outcomes of installing touchless water dispensers in schools with the costs and outcomes associated with not implementing the voluntary water equity and access program over 10 years (2020-2029).

The installation of touchless water dispensers in schools in Massachusetts is an investment in a more equitable future. By the end of 2029:

Conclusions and Implications

Installing water dispensers in K-8 public schools is an effective strategy for increasing access to clean and appealing drinking water, and over 10 years, it could improve drinking water access for 265,000 students in 304 schools in Massachusetts. Adequate water consumption can support well-being and cognitive function.⁹ Fluoridated water intake also prevents dental caries.¹⁰ Such preventive strategies play a critical role in promoting child health. This strategy is also projected to prevent 525 cases of childhood obesity in 2029 and cost, on average, $9 per child to implement each year. It is likely to be cost-effective at commonly accepted thresholds¹¹ based on net cost per population health improvement related to excess weight, at a cost of $72,700 per quality-adjusted life year gained.

In Massachusetts, schools that participate in the state’s drinking water lead testing program are eligible to receive funding to install water dispensers.¹² Expanding participation in this opportunity for drinking water testing and fixture installation would provide students and staff with better access to more appealing drinking water. Additionally, the proposed outreach strategy would prioritize installing water dispensers in schools that identify elevated concentrations of lead in their drinking water and in school districts located in communities meeting criteria for Environmental Justice designation.⁸ Because these communities have a higher proportion of residents who identify as people of color or households with low income, this strategy could promote health equity. Fifty percent of the students that would gain access to improved drinking water would be Black and Hispanic/Latinx, a higher proportion than the state’s student population overall.¹³

Though investment is required, every student deserves access to clean, appealing drinking water at school and this strategy would support the health of both students and staff in Massachusetts’ schools.

References

MA Executive Office of Energy and Environmental Affairs. Lead and Copper in School Drinking Water Sampling Results. Accessed December 5, 2022. https://www.mass.gov/service-details/lead-and-copper-in-school-drinking-water-sampling-results
Massachusetts Department of Elementary and Secondary Education. 2021 Youth Risk Behavior Survey (YRBS) Results. 2021.
Malik VS, Pan A, Willett WC , Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98(4):1084-1102.
Chen L, Caballero B, Mitchell DC, et al. Reducing consumption of sugar-sweetened beverages is associated with reduced blood pressure a prospective study among United States adults. Circulation. 2010;121(22):2398-2406.
Bogart LM, Babey SH, Patel AI, Want P, Schuster MA. Lunchtime school water availability and water consumption among California adolescents. J Adolesc Health. 2016; 58(1):98-103, doi: 10.1016/j.jadohealth.2015.09.007.
Schwartz AE, Leardo M, Aneja S, Elbel B. Effect of a School-Based Water Intervention on Child Body Mass Index and Obesity. JAMA Pediatr. 2016; 170(3):220-226. doi:10.1001/jamapediatrics.2015.3778.
Kenney EL, Cradock AL, Long MW, et al. Cost-Effectiveness of Water Promotion Strategies in Schools for preventing Childhood Obesity and Increasing Water Intake. Obesity. 2019;27(12):2037-2045.
MA Executive Office of Energy and Environmental Affairs. Environmental Justice Populations in Massachusetts. Accessed April 7, 2023. https://www.mass.gov/info-details/environmental-justice-populations-in-massachusetts
Popkin BM, D’Anci KE, Rosenberg IH. Water, hydration, and health. Nutr Rev. 2010 Aug;68(8):439-58.
American Dental Association and Centers for Disease Control. Nature’s Way to Prevent Tooth Decay: Water Fluoridation. Published 2006. Accessed July 13, 2021. https://www.cdc.gov/fluoridation/pdf/natures_way.pdf
Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness–the curious resilience of the $50,000-per-QALY threshold. New England Journal of Medicine. 2014 Aug 28;371(9):796-7. doi: 10.1056/NEJMp1405158. PMID: 25162885.
The Massachusetts Clean Water Trust. About SWIG. Accessed May 5, 2022. https://www.mass.gov/service-details/about-swig
Massachusetts Department of Elementary and Secondary Education. 2022-23 Enrollment By Race/Gender Report (District). Updated December 1, 2022. Accessed April 7, 2023. https://profiles.doe.mass.edu/statereport/enrollmentbyracegender.aspx

Suggested Citation:

McCulloch SM, Barrett JL, Reiner JF, Cradock AL, Gortmaker SL. Massachusetts: Water Dispensers in Schools {Issue Brief}. The CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; June 2023. For more information, please visit www.choicesproject.org

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This issue brief was developed at the Harvard T.H. Chan School of Public Health through the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. This work is supported by 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.

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Brief: Movement Breaks in the Classroom in Massachusetts

Posted on June 22, 2023

School children stretching during a movement break during class time

The information in this brief is intended only to provide educational information.

This brief summarizes a CHOICES Learning Collaborative Partnership model examining a strategy to incorporate movement breaks, five-to-10-minute physical activity breaks during class time, into school classrooms in Massachusetts.

The Issue

Every child should have opportunities to be physically active. Students who are physically active tend to have better grades,¹ attendance in school,¹ and stronger muscles and bones.² Regular physical activity can improve cognition, reduce symptoms of depression, help children maintain a healthy weight, and prevent risk of future chronic disease.²

Experts suggest that schools can provide students with opportunities to be physically active to help meet the national recommendation of 60 minutes per day.² Incorporating five-to-10-minute movement breaks during class time can supplement other school physical activity opportunities, like physical education and recess. While some Massachusetts public schools offer classroom movement breaks at the middle school level,³ there are little to no data suggesting classroom movement breaks are provided for all younger students. Helping all classroom teachers integrate best practices for movement breaks will ensure more students have an opportunity to be active and help children grow up healthy and ready to learn.

About the Movement Breaks in the Classroom Strategy

To implement this evidence-based strategy,⁴ the Massachusetts Departments of Public Health and Elementary and Secondary Education would collaborate to connect school districts to the School Wellness Coaching Program. This program helps school districts integrate movement breaks into their local wellness policies and meet state and federal physical activity recommendations. Teachers in kindergarten to fifth-grade classrooms would receive training, technical assistance, and materials to support implementation. School wellness champions could also elect to be trained. This strategy aligns with the School Wellness Coaching Program⁵ and the Whole School, Whole Community, Whole Child initiative⁶ to create school environments that prioritize students’ health, well-being, and ability to learn.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes over a 10-year time horizon (2020-2029) of implementing movement breaks in the classroom with the costs and outcomes associated with not implementing the program.

Integrating movement breaks in the classroom is an investment in the future. By the end of 2029:

Conclusions and Implications

Not all students have access to safe streets, playgrounds, or spaces to be physically active. If movement breaks were incorporated into classrooms in Massachusetts, 31,600 elementary school students would benefit. These students could increase their moderate-to-vigorous physical activity levels by 25 minutes per school week, helping them reach the recommended physical activity levels.² We project that 36 cases of obesity would be prevented in 2029 and $30,800 in health care costs related to excess weight would be saved over 10 years. This strategy would cost less than $6 per child per year to implement in Massachusetts and is likely to be cost-effective at commonly accepted thresholds⁷ based on net cost per population health improvement related to excess weight ($66,200 per quality-adjusted life year gained).

Classroom movement breaks provide all students with the opportunity to be physically active. This is particularly important for those students with fewer options outside of school. By training and equipping over 200 teachers and other school staff to incorporate movement breaks in the classroom, this strategy could help Massachusetts public schools cultivate a positive school climate and improve social emotional learning.⁸ Additionally, movement breaks allow students an opportunity for a “brain break” to refocus, reconnect and bring their attention back to their academic work. Students who participate in movement breaks spend more time on task⁴ and teachers report that students are more engaged, supportive of each other, and responsive to teacher instructions after participating in a movement break.⁹

Regular physical activity is important for healthy growth and development. Many preventive strategies can play a critical role in helping children establish healthy habits early on in life. Movement breaks provide an opportunity to invest in students and support their healthy growth and academic success.

References

Centers for Disease Control and Prevention. The Association Between School-Based Physical Activity, Including Physical Education, and Academic Performance. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2020-04-21T09:02:35Z 2010.
US Dept of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. US Dept of Health and Human Services; 2018. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf
Centers for Disease Control and Prevention. School Health Profiles 2018: Characteristics of Health Programs Among Secondary Schools. Centers for Disease Control and Prevention;2019:205. https://www.cdc.gov/healthyyouth/data/profiles/pdf/2018/CDC-Profiles-2018.pdf
The Community Preventive Services Task Force. Physical Activity: Classroom-based Physical Activity Break Interventions. The Community Guide; 2021. Accessed Jun 20, 2023. https://www.thecommunityguide.org/pages/tffrs-physical-activity-classroom-based-physical-activity-break-interventions.html
School Wellness Initiative for Thriving Community Health (SWITCH). Initiatives: Massachusetts School Wellness Coaching Program. Published 2022. Accessed Oct 5, 2022. https://massschoolwellness.org/initiatives
Massachusetts Department of Elementary and Secondary Education. Student and Family Support (SFS): Whole School, Whole Community, Whole Child (WSCC). Published 2021. Accessed Oct 5, 2022. https://www.doe.mass.edu/sfs/wscc
Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness–the curious resilience of the $50,000-per-QALY threshold. New England Journal of Medicine. 2014 Aug 28;371(9):796-7. DOI: 10.1056/NEJMp1405158. PMID: 25162885.
Centers for Disease Control and Prevention. School-Based Physical Activity Improves the Social and Emotional Climate for Learning. CDC Healthy Schools. Published 2021. Accessed March 9, 2022. https://www.cdc.gov/healthyschools/school_based_pa_se_sel.htm
Campbell AL, Lassiter JW. Teacher perceptions of facilitators and barriers to implementing classroom physical activity breaks. Journal of Educational Research. 2020;113(2):108-119. DOI: 10.1080/00220671.2020.1752613

Suggested Citation:

Good N, Bolton AA, Barrett JL, Reiner JF, Cradock AL, Gortmaker SL. Massachusetts: Movement Breaks in the Classroom {Issue Brief}. The CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; June 2023. For more information, please visit www.choicesproject.org

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

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Report: Sugary Drink Excise Tax in Minnesota

Posted on August 12, 2022

The information in this report is intended to provide educational information on the cost-effectiveness of sugary drink excise taxes.

Executive Summary

Continually rising rates of obesity represent one of the greatest public health threats facing the United States. Obesity has been linked to excess consumption of sugary drinks. Federal, state, and local governments have considered implementing excise taxes on sugary drinks to reduce consumption, reduce obesity, and provide a new source of government revenue.^1-4Seven cities in the United States have implemented sugary drink taxes.

We modeled potential implementation of a state excise tax in Minnesota, a tax on sugary drinks only, at a tax rate of $0.02/ounce. Powdered drink mixes were modeled at a tax rate of $0.0025 per reconstituted fluid ounce according to the package instructions.

The tax is projected to be cost-saving and result in lower levels of sugary drink consumption, thousands of cases of obesity prevented, more than $160 million dollars in health care cost savings, and improved health equity. The tax is projected to save $45.60 in health care costs per dollar invested.

Background

Although consumption of sugary drinks (defined as all drinks with added caloric sweeteners) has declined in recent years, adolescents and young adults in the United States consume more sugar than the Dietary Guidelines for Americans 2020-2025 recommend, with persistent racial/ethnic disparities.^5-8 According to recent estimates, 22% of adults in Minnesota drink at least one soda or other sugary drink per day.⁹ The Minnesota Student Survey of sixth, ninth and twelfth graders found that three out of four students reported consuming a sugary drink a day.¹⁰ Public health researchers have suggested that excess intake of sugary drinks may be one of the single largest drivers of the obesity epidemic in the U.S.¹¹ An estimated 63% of adults and 22% of youth in Minnesota have overweight or obesity.^10,12

Targeted marketing contributes to differences in consumption by race/ethnicity group. Non-Hispanic Black youth are twice as likely as non-Hispanic White youth to see TV ads for sugary drinks.¹³ Non-Hispanic Black and Hispanic youth are less likely to be the audience for marketing of more healthy beverages, like water.¹⁴ Consumption of sugary drinks increases the risk of chronic diseases through changes in body mass index (BMI), insulin regulation, and other metabolic processes.^15-17 Randomized intervention trials and longitudinal studies have linked increases in sugary drink consumption to excess weight gain, diabetes, cardiovascular disease, and other health risks.^15,16 There are persistent racial and ethnic disparities across rates of obesity and chronic disease.^5-7 In light of this evidence, the Dietary Guidelines for Americans 2020-2025⁸ recommends that individuals limit sugary drink intake in order to manage body weight and reduce risk of chronic disease.

Taxation has emerged as one recommended strategy to reduce consumption of sugary drinks.¹⁸ This strategy has been studied by public health experts, who have drawn on the success of tobacco taxation and decades of economic research to model the estimated financial and health impact of a sugary drink excise tax.^19-22 This report provides information on a model of the projected effect of sugary drink excise taxes on health and disease outcomes over 10 years. For the purposes of this model, sugary drinks include all drinks with added caloric sweeteners; beverages with less than two calories per ounce were exempt from the model. Proposed and enacted sugary drink excise taxes typically do not apply to 100% juice or milk products and these are exempt from the modeled tax.

Modeling Framework: How excise taxes can lead to better health

State excise tax is linked to change in BMI through change in sugary drink price and consumption

Key Terms

Excise tax: a consumption tax collected from retailers or distributors; it is reflected in the posted price (a sales tax in contrast is applied after purchase of the item)
Pass-through rate: how much of the excise tax on distributors is passed on to consumers as an increase in shelf price; a percent ranging from 0% (none of the tax) to 100% (all the tax)
Price elasticity of demand: how much consumer purchasing behavior changes following a change in price of an item

How does an excise tax work?

How does an excise tax on distributors affect the price paid by consumers?

Since the cost of a sugary drink excise tax is incorporated directly into the beverage’s sticker price, an excise tax will likely influence consumer purchasing decisions more than a comparable sales tax that is added onto the item at the register. We assume 100% pass-through of the tax over 10 years and assume the tax rate would be adjusted annually for inflation. Our pass-through rate estimate is supported by empirical studies of excise taxes in Mexico and France that demonstrate near-complete pass through rates to consumers.²³ Short term studies for the local tax in Berkeley indicate imperfect, or less than 100%, pass-through.^3,24,25 The expected change in sugary drink price was estimated using an average of $0.06/ounce based on national sugary drink prices.²⁶ The price per ounce in this study was based on a weighted average of sugary drink consumption across stores, restaurants and other sources according to the estimates from the National Health and Nutrition Examination Survey (NHANES) 2009-2010. The price per ounce of sugary drinks purchased in stores was calculated using weighted averages of two-liter bottles, 12-can cases, and single-serve containers based on 2010 Nielsen Homescan data.²⁶ For example, a $0.02/ounce tax would raise the price of a 12-ounce can of soda from $0.72 to $0.96/can post-tax.

How does increasing the price of sugary drinks change individual sugary drink consumption?

To estimate current sugary drink consumption levels in Minnesota, we used local estimates of adult sugary drink consumption from the Minnesota Behavioral Risk Factor Surveillance System¹² and child sugary drink consumption from the Minnesota Student Survey²⁷ based on race/ethnicity to adjust national estimates of sugary drink consumption from NHANES 2011-2014. How much consumers will change their purchases in response to price changes is called price elasticity for demand. We assume for every 10% increase in the price of sugary drinks, there will be a 12% reduction in purchases (a mean own-price elasticity of demand of -1.21).²⁸ Recent research on the Berkeley, CA $0.01/ounce tax found a 21% reduction in sugary drink intake among populations experiencing low income, consistent with this estimate.^24,29-32 More recent data before and after the sugary drink tax in Philadelphia indicate a larger own-price elasticity for sugary drinks.³⁰

What are the individual health effects of decreasing sugary drink consumption?

Research has shown that decreasing sugary drink consumption can have positive effects on health in adults and youth. We estimated the impact of a change in sugary drink intake on body mass index (BMI), accounting for dietary compensation, based on rigorous studies identified in evidence reviews.²² The relationship among adults was modeled based on the range of estimated effects from four large, multi-year longitudinal studies, which indicated that a one-serving reduction in sugary drinks was associated with a BMI decrease of 0.21 kg/m² to 0.57 kg/m² in adults over a three-year period.^16,33-35 Among youth, we used evidence from a double-blind randomized controlled trial conducted over 18 months, which found that reducing sugary drinks by eight ounces per day led to less weight gain (2.2 fewer pounds).³⁶

Reach

The intervention applies to all children and adults in Minnesota. However, the model only looks at the effects on those 2 years of age and older.*

*BMI z-scores were used in our analyses, which are not defined for children under 2 years of age.

Cost

We assume the tax would incur start up and ongoing labor costs for tax administrators in the Minnesota Department of Revenue. To implement the intervention, the Minnesota Department of Revenue would need to process tax statements and conduct audits. Businesses would also need to prepare tax statements and participate in audits, which would require labor from private tax accountants. Cost information was drawn from localities with planned or implemented excise taxes on soft drinks to reflect the total estimated costs.^22,37 The cost and benefit estimates do not include expected tax revenue.

CHOICES Microsimulation Model

The CHOICES microsimulation model for Minnesota was used to calculate the costs and effectiveness over 10 years (2017–2027). Cases of obesity prevented were calculated at the end of the model period in 2027. The model was based on prior CHOICES work,^22,38 and created a virtual population of Minnesota residents using data from: U.S. Census, American Community Survey, Behavioral Risk Factor Surveillance System,¹² NHANES, National Survey of Children’s Health,³⁹ the Medical Expenditure Panel Survey, multiple national longitudinal studies, and obesity prevalence data provided by the Minnesota Department of Health. Using peer-reviewed methodology, we forecasted what would happen to this virtual population with and without a sugary drink tax to model changes in disease and mortality rates and health care costs due to the tax.

Results: $0.02/ounce State Excise Tax on Sugary Drinks

Overall, the model projects that a sugary drink excise tax is cost-saving. Compared to the simulated natural history without a tax, the tax is projected to result in lower levels of sugary drink consumption, fewer cases of obesity, fewer deaths, and health care savings greater than $160 million dollars over the 10-year period under consideration.

The estimated reduction in obesity attributable to the tax leads to lower projected health care costs, offsetting tax implementation costs and resulting in net cost savings. The difference between total health care costs with no intervention and lower health care costs with an intervention represent health care costs saved; these savings can be compared to the cost of implementing the tax to arrive at the metric of health care costs saved per $1 invested.

Outcome	$0.02/ounce excise tax Mean (95% uncertainty interval)
10-Year Reach*	6,060,000 (6,040,000; 6,070,000)
First Year Reach*	5,400,000 (5,400,000; 5,410,000)
Average Servings of Sugary Drinks Consumed per Year Prior to the Modeled Tax	215 (215; 217)
Decrease in 12-Ounce Servings of Sugary Drinks per Person in the First Year of the Intervention*	77.6 (48.3; 142)
Mean Reduction in BMI Units per Person*	-0.169 (-0.312; -0.087)
10-Year Intervention Implementation Cost per Person	$0.61 ($0.49; $0.73)
Total Intervention Implementation Cost Over 10 Years**	$3,700,000 ($2,980,000; $4,390,000)
Annual Intervention Implementation Cost	$370,000 ($298,000; $439,000)
Health Care Costs Saved Over 10 Years	$169,000,000 ($82,400,000; $353,000,000)
Net Costs Difference Over 10 Years	-$165,000,000 (-$349,000,000; -$78,300,000)
Quality Adjusted Life Years (QALYs) Gained Over 10 Years	8,190 (3,900; 17,200)
Years of Life Gained Over 10 Years	2,110 (798; 4,920)
Deaths Prevented Over 10 Years*	607 (233; 1,450)
Years with Obesity Prevented Over 10 Years	242,000 (129,000; 449,000)
Health Care Costs Saved per $1 Invested Over 10 Years	$45.60 ($21.80; $94.70)
Cases of Obesity Prevented in 2027*	34,700 (18,600; 64,200)
Cases of Childhood Obesity Prevented in 2027*	9,250 (4,220; 18,800)
Cost per Year with Obesity Prevented Over 10 Years	Cost-saving
Cost per QALY Gained Over 10 Years	Cost-saving
Cost per YL Gained Over 10 Years	Cost-saving
Cost per Death Averted Over 10 Years	Cost-saving

Uncertainty intervals are estimated by running the model 1,000 times, taking into account both uncertainty from data sources and virtual population projections, and calculating a central range in which 95 percent of the model results fell.

All metrics reported for the population over a 10-year period and discounted at 3% per year, unless otherwise noted.

*Not discounted.

**Total estimated costs for the Department of Revenue and businesses to implement the tax.

Results: ^$0.02/ounce State Excise Tax on Sugary Drinks By Race/Ethnicity Groups

There are differences in sugary drink consumption and obesity prevalence by race/ethnicity in Minnesota. The CHOICES model used Minnesota data to build a virtual Minnesota population. Without any intervention:

Sugary drink consumption is higher in several communities of color in Minnesota

Obesity prevalence is highest in the Black/African American, Hispanic/Latino, and Native American or Alaskan populations

Outcome	Asian Mean (95% uncertainty interval)	Black/African American Mean (95% uncertainty interval)	Hispanic/Latino Mean (95% uncertainty interval)	Native American or Alaskan Mean (95% uncertainty interval)	Multiracial Mean (95% uncertainty interval)	Other Mean (95% uncertainty interval)	White Mean (95% uncertainty interval)
Average Servings of Sugary Drinks Consumed per Year Prior to the Modeled Tax	206 (203; 208)	380 (374; 386)	348 (343; 353)	479 (469; 492)	361 (355; 367)	224 (211; 239)	186 (185; 187)
Decrease in 12-Ounce Servings of Sugary Drinks per Person in the First Year*	72.8 (45.6; 129)	136 (84.9; 237)	126 (78.7; 222)	173 (107; 317)	130.2 (81.6; 235)	80.3 (49.6; 150)	67.2 (41.6; 121)
Reduction in Obesity Prevalence	0.42%	1.28%	1.43%	1.29%	1.09%	0.48%	0.51%
QALYs Gained Over 10 Years	189 (83; 391)	744 (355; 1,520)	675 (334; 1,350)	225 (89; 516)	241 (100; 489)	12 (3; 47)	6,110 (2,820; 12,900)
Years of Life Gained Over 10 Years	31 (0; 99)	180 (33; 479)	82 (0; 236)	67 (0; 204)	47 (0; 147)	5 (0; 46)	1,690 (626; 3,940)
Additional Years Lived without Obesity (2017-2027)	7,920 (3,770; 15,200)	28,500 (15,800; 49,400)	32,700 (17,100; 56,900)	6,100 (3,200; 10,900)	12,200 (5,990; 22,700)	322 (152; 623)	154,000 (78,800; 289,000)
Cases of Obesity Prevented in 2027*	1,150 (552; 2,220)	4,130 (2,190; 7,410)	4,790 (2,440; 8,170)	842 (411; 1,520)	1,750 (835; 3,330)	52 (17; 113)	22,000 (11,500; 42,100)
Cases of Childhood Obesity Prevented in 2027*	463 (164; 1,080)	1,380 (637; 2,680)	1,680 (740; 3,340)	203 (70; 502)	858 (359; 1,860)	18 (4; 48)	4,650 (2,110; 9,600)

All metrics reported for the population over a 10-year period and discounted at 3% per year, unless otherwise noted.

*Not discounted.

Communities of color make up:

Metric
Metric	Asian	Black/African American	Hispanic/ Latino	Native American or Alaskan	Multiracial	Other	White
Percent of Total Population in 2027*	5%	6%	6%	1%	3%	<1%	79%
Total Number of Cases of Obesity Prevented in 2027	1,150	4,130	4,790	842	1,750	52	22,000
Percent of Total Number of Cases of Obesity Prevented in 2027*	3%	12%	14%	2%	5%	<1%	63%

*All race/ethnicity data represents broad groupings. Due to data limitations, we were not able to identify subgroups within these broad categories. Some populations within each category with different lived experiences (income, immigrant/non-immigrant, social position, etc.) may differ significantly from the broad grouping related to obesity, sugary beverage consumption, and the impact of the excise tax.

Impact on Diabetes

We estimated the impact of the tax-induced reduction in sugary drink intake on diabetes incidence for adults ages 18-79 years using a published meta-analysis of the relative risk of developing diabetes due to a one-serving change in sugary drink consumption⁴⁰ as well as local estimates of diabetes. On average, each 8.5 ounce serving of sugary drinks per day is estimated to increase the risk of diabetes by 18%.⁴⁰

In Minnesota, we estimated that the proposed sugary drink excise tax would lead to a 3% reduction in diabetes incidence in the sugary drink tax models. Impact on diabetes incidence was calculated over a one-year period once the tax reaches its full effect. Impact on diabetes was calculated based on summary results from the model, not directly via microsimulation.

Impact on Tooth Decay

We estimated the impact of a sugary drink excise tax on tooth decay cost using a longitudinal analysis of the relationship between intake of sugars and tooth decay in adults. On average, for every 10 grams higher intake of sugar per day, there is an increase in decayed, missing, and filled teeth (i.e., tooth decay) of approximately 0.10 over 10 years.⁴¹ As described above, we assume that the excise tax will result in a reduction in sugary drink intake. There are many studies showing a similar relationship between higher intake of sugars and tooth decay in children and youth⁴² and thus we assume the same relationship as found in adults.

We used 2018 Minnesota Health Care Programs procedure code⁴³ data to estimate a Medicaid cost of treating tooth decay as: $149.71 for a permanent crown in children and $32.57 for a filling in children. These codes reflect treatment for one surface and do not reflect higher reimbursement rates for multi-surface treatment, temporary crowns, or potential flat tax schedules. Based on analysis of data on tooth decay, fillings and crowns for the U.S. population from NHANES 1988-1994 (the last year crowns and fillings were separately reported),⁴⁴ we estimate that 78.9% of tooth decay in children is fillings. Using this same data set, we estimate that 97.5% of treatment for children is fillings.

To estimate Medicaid-specific dental caries cost savings, we used local estimates of the numbers of people enrolled in Medicaid and the proportion receiving Medicaid dental services. Because of limited Medicaid dental coverage for adults in Minnesota, only children are included in the Medicaid-specific calculations. In Minnesota, we estimate that a $0.02/ounce tax would lead to a total over a period of 10 years in tooth decay savings of $227,000 in Medicaid savings. The Medicaid reimbursement tax estimates may underestimate the total cost savings of tooth decay treatment projected here as dental providers may charge higher amounts to patients.

Potential Yearly Sugary Drink Tax Revenue from a ^$0.02/ounce Sugary Drink Tax

In addition to the projected cost savings of $165 million in net costs over 10 years, an excise tax will generate substantial annual revenue. A $0.02/ounce tax on sugary drinks in Minnesota could raise $213 million. This estimate of potential revenue assumes 50% of the projection reported on the Rudd Center Revenue Calculator for Sugary Drink Taxes (Rudd Calculator).⁴⁵ The Rudd Calculator, which bases estimates on regional sales data adjusted for state or city specific demographics,⁴⁶ is “intended to provide a rough estimate and starting point to project the revenue from a tax on sugary drinks.”⁴⁵ Several factors could impact the potential for the tax to raise that amount. Retailers may have inventories of sugary drinks obtained before the tax was implemented. Residents living close to city, county and/or state borders may also purchase sugary drinks in neighboring communities without such a tax. Finally, there may be some distributors/manufacturers that are non-compliant with the tax. The Rudd sales data for specific states and/or cities within those regions may also vary from the regional average. The Rudd Calculator notes that users of the calculators are “advised to adjust the revenues down by 10%-30%.”⁴⁵ For Minnesota, we provide a revenue projection assuming 50% of the Rudd Calculator projection, since surveillance data indicate that consumption of sugary drinks in Minnesota is low compared with other states in the region.^46,47

Considerations for Health Equity

Concerns have been raised regarding the impact of the tax on households with low income because populations with low income tend to consume more sugary drinks.⁴⁸ Economic studies indicate that with a sugary drink tax, consumers will buy less of these products.²⁸ This change in purchasing is substantial, so that consumers can be expected to spend less on sugary drinks after a tax is implemented. Using sales data from the Rudd Center Revenue Calculator for Sugary Drink Taxes (Rudd Calculator),⁴⁵ we project that individuals and households in Minnesota will spend less money on sugary drinks after the tax. This would free up disposable income for other consumer purchases.

In addition to these changes in spending, health benefits are projected to be greatest among individuals with low income. We project that more health benefits from this policy will accrue to consumers with low income; the same is true for a number of racial and ethnic groups. Beverage companies frequently target their sugary drink advertising towards youth, and are more likely to target Black and Hispanic/Latino youth.¹³ In Minnesota, the average percentage of adults who drink one or more soda or sugary drink per day varies by racial and ethnic group, for example from 20% of non-Hispanic White adult residents to 39% of Hispanic/Latino adult Minnesota residents.⁹ Under the proposed tax, we project that Native American or Alaskan, Hispanic/Latino, Multiracial, and Black/African American Minnesota residents would see twice as high of a reduction in obesity prevalence compared to non-Hispanic White Minnesota residents. On that basis. the proposed tax should decrease inequities in obesity outcomes and improve health equity. These expected changes in sugary drink consumption and health outcomes have led health economists to calculate that populations with lower income have benefit from sugary drink taxes.⁴⁹ In addition, revenue from a sugary drink tax could be reinvested in communities with lower income through a variety of approaches.⁵⁰

Implementation Considerations

Revenue raised from a sugary drink tax can be reinvested in communities experiencing low income. For instance, in Berkeley, CA, sugary drink tax revenue has been allocated for spending on school and community programs, many serving populations with low income or communities of color to promote healthy eating, diabetes and obesity prevention.^51,52 Public support for such taxes generally increases with earmarking for preventive health activities.⁵²

There is opposition from the food and beverage industry, which spends billions of dollars promoting their products.⁵³ Relatively small beverage excise taxes are currently applied across many states. The proposed tax is likely to be sustainable if implemented based on the successful history of tobacco excise taxes. There is potential for a shift in social norms of sugary drink consumption based on evidence from tobacco control tax and regulatory efforts.⁵³ Implementing the tax could also serve as a powerful health education message to reduce added sugar consumption.

Conclusion

We project that a $0.02 per ounce sugary drink excise tax in Minnesota will prevent thousands of cases of childhood and adult obesity, improve health equity, prevent new cases of diabetes, increase healthy life years, and save more in future health care costs than it costs to implement. Revenue from the tax could be used for education and health promotion efforts. Implementing the tax could also serve as a powerful social signal to reduce sugar consumption.

Suggested Citation:

Ambroz TA, Pelletier JE, Long MW, Ward ZJ, Giles CM, Barrett JL, Cradock AL, Resch SC, Greatsinger A, Tao H, Flax CN, Gortmaker SL. Minnesota: Sugary Drink Excise Tax [Report]. Minnesota Department of Health, St. Paul, MN, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; August 2022.

The design for this report and its graphics were developed by Molly Garrone, MA and partners at Burness.

Funded by The JPB Foundation. Results are those of the authors and not the funders.

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References

American Public Health Association Taxes on Sugar-Sweetened Beverages. 2012.
Hakim D, Confessore N. Paterson seeks huge cuts and $1 billion in taxes and fees. New York Times. January 19, 2010.
Falbe J, Rojas N, Grummon AH, Madsen KA. Higher Retail Prices of Sugar-Sweetened Beverages 3 Months After Implementation of an Excise Tax in Berkeley, California. American Journal of Public Health. 2015;105(11):2194-2201.
Leonhardt D. The battle over taxing soda. The New York Times. May 19, 2010.
Kit BK, Fakhouri THI, Park S, Nielsen SJ, Ogden CL. Trends in sugar-sweetened beverage consumption among youth and adults in the United States: 1999-2010. American Journal of Clinical Nutrition. 2013;98(1):180-188.
Bleich SN, Vercammen KA, Koma JW, Li ZH. Trends in Beverage Consumption Among Children and Adults, 2003-2014. Obesity. 2018;26(2):432-441.
Vercammen KA, Moran AJ, Soto MJ, Kennedy-Shaffer L, Bleich SN (2020). Decreasing Trends in Heavy Sugar-Sweetened Beverage Consumption in the United States, 2003-2016. Journal of the Academy of Nutrition and Dietetics. 2020 Dec;120(12):1974-1985.e5.
U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2020 – 2025 Dietary Guidelines for Americans. December 2020.
Park S, Xu F, Town M, Blanck H. Prevalence of Sugar-Sweetened Beverage Intake Among Adults – 23 States and the District of Columbia. MMWR Morb Mortal Wkly Report 2016. 2013;65(7):169-174.
Minnesota Department of Health. Minnesota Student Survey. Minnesota Department of Health, Minnesota Center for Health Statistics; 2013.
Brownell KD, Frieden TR. Ounces of Prevention – The Public Policy Case for Taxes on Sugared Beverages. N Engl J Med. 2009;360(18):1805-1808.
Minnesota Department of Health. Minnesota Behavioral Risk Factor Surveillance Survey (BRFSS). Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health; 2013.
Harris J, Shehan C, Gross R, et al. Food advertising targeted to Hispanic and Black youth: Contributing to health disparities. August 2015.
Yancey AK, Cole BL, Brown R, et al. A cross-sectional prevalence study of ethnically targeted and general audience outdoor obesity-related advertising. Milbank Q. 2009;87(1):155-184.
Malik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. The American Journal of Clinical Nutrition. 2013;98(4):1084-1102.
Chen L, Caballero B, Mitchell DC, et al. Reducing Consumption of Sugar-Sweetened Beverages Is Associated with Reduced Blood Pressure: A Prospective Study among U.S. Adults. Circulation. 2010;121(22):2398-2406.
Wang Y. The potential impact of sugar-sweetened beverage taxes in New York State. A report to the New York State Health Commissioner. New York: Columbia Mailman School of Public Health. 2010.
IOM (Institute of Medicine), National Research Council. Local Government Actions to Prevent Childhood Obesity. Washington, DC: The National Academies Press; 2009.
Chaloupka F, Powell L, Chriqui J. Sugar-sweetened beverage taxes and public health: A Research Brief. Minneapolis, MN2009.
Brownell KD, Farley T, Willett WC, et al. The Public Health and Economic Benefits of Taxing Sugar-Sweetened Beverages. N Engl J Med. 2009;361(16):1599-1605.
Long M, Gortmaker S, Ward Z, et al. Cost Effectiveness of a Sugar-Sweetened Beverage Excise Tax in the U.S. Am J Prev Med. 2015;49(1):112-123.
Gortmaker SL, Wang YC, Long MW, et al. Three Interventions That Reduce Childhood Obesity Are Projected To Save More Than They Cost To Implement. Health Aff. 2015;34(11):1932-1939.
Colchero MA, Salgado JC, Unar-Munguia M, Molina M, Ng SW, Rivera-Dommarco JA. Changes in Prices After an Excise Tax to Sweetened Sugar Beverages Was Implemented in Mexico: Evidence from Urban Areas. PLoS One. 2015;10(12):11.
Falbe J, Thompson HR, Becker CM, Rojas N, McCulloch CE, Madsen KA. Impact of the Berkeley Excise Tax on Sugar-Sweetened Beverage Consumption. American Journal of Public Health. 2016;106(10):1865-1871.
Ng S, Silver L, Ryan-Ibarra S, et al. Berkeley Evaluation of Soda Tax (BEST) Study Preliminary Findings. Presentation at the annual meeting of the American Public Health Association. Paper presented at: Presentation at the annual meeting of the American Public Health Association; November, 2015; Chicago, IL.
Powell L, Isgor z, Rimkus L, Chaloupka F. Sugar-sweetened beverage prices: Estimates from a national sample of food outlets. Chicago, IL: Bridging the Gap Program, Health Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago;2014.
Minnesota Department of Health. Minnesota Student Survey. Minnesota Department of Health, Minnesota Center for Health Statistics; 2007-2016
Powell LM, Chriqui JF, Khan T, Wada R, Chaloupka FJ. Assessing the Potential Effectiveness of Food and Beverage Taxes and Subsidies for Improving Public Health: A Systematic Review of Prices, Demand and Body Weight Outcomes. Obesity Reviews. 2013;14(2):110-128.
Roberto CA, Lawman HG, LeVasseur MT, Mitra N, Peterhans A, Herring B, Bleich SN. Association of a Beverage Tax on Sugar-Sweetened and Artificially Sweetened Beverages With Changes in Beverage Prices and Sales at Chain Retailers in a Large Urban Setting. JAMA. 2019 May 14;321(18):1799-1810. doi: 10.1001/jama.2019.4249.
Lee MM, Falbe J, Schillinger D, Basu S, McCulloch CE, Madsen KA. Sugar-Sweetened Beverage Consumption 3 Years After the Berkeley, California, Sugar-Sweetened Beverage Tax. American Journal of Public Health. 2019;109(4):637-639.
Zhong Y, Auchincloss AH, Lee BK, Kanter GP. The Short-Term Impacts of the Philadelphia Beverage Tax on Beverage Consumption. American Journal of Preventive Medicine. 2018;55(1):26-34.
Silver LD, Ng SW, Ryan-Ibarra S, et al. Changes in prices, sales, consumer spending, and beverage consumption one year after a tax on sugar-sweetened beverages in Berkeley, California, US: A before-and-after study. PLoS Medicine. 2017;14(4):e1002283
Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB. Changes in Diet and Lifestyle and Long-Term Weight Gain in Women and Men. New England Journal of Medicine. 2011;364(25):2392-2404.
Palmer JR, Boggs DA, Krishnan S, Hu FB, Singer M, Rosenberg L. Sugar-Sweetened Beverages and Incidence of Type 2 Diabetes Mellitus in African American Women. Archives of Internal Medicine. 2008;168(14):1487-1492.
Schulze MB, Manson JE, Ludwig DS, et al. Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. Journal of the American Medical Association. 2004;292(8):927-934.
de Ruyter JC, Olthof MR, Seidell JC, Katan MB. A trial of sugar-free or sugar-sweetened beverages and body weight in children. New England Journal of Medicine. 2012;367(15):1397-1406.
Healthy Food America. Implementing Sugary Drink Taxes: Outreach, Collection, and Fighting Industry Litigation. [Webinar]. 2017; http://www.healthyfoodamerica.org/webinars.
Ward ZJ, Long MW, Resch SC, Giles CM, Cradock AL, Gortmaker SL. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. N Engl J Med. 2017;377(22):2145-2153.
Long MW, Ward Z, Resch SC, et al. State-level estimates of childhood obesity prevalence in the United States corrected for report bias. Int J Obes. 2016;40(10):1523-1528.
Imamura F, O’Connor L, Ye Z, Mursu J, Hayashino Y, Bhupathiraju SN, Forouhi NG. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes. Br J Sports Med. 2016 Apr;50(8):496-504
Bernabé E, Vehkalahti MM, Sheiham A, Lundqvist A, Suominen AL. The Shape of the Dose-Response Relationship between Sugars and Caries in Adults. J Dent Res. 2016;95(2):167-172.
Sheiham A, James WPT. A new understanding of the relationship between sugars, dental caries and fluoride use: implications for limits on sugars consumption. Public Health Nutr. 2014;17(10):2176-2184.
Minnesota Health Care Program (MHCP) Minnesota Health Care Program Reimbursement Fee Schedule. 2018.
Ward Z, et al. NHANES III Dental Examination: An Incisive Report. unpublished report; 2018.
UConn Rudd Center for Food Policy & Obesity. Sugary Drink Tax Calculator. https:// uconnruddcenter.org/tax-calculator. Accessed February 2021.
Andreyeva T, Chaloupka F, Powell L. DATA AND ASSUMPTIONS (TAX CALCULATOR REVISION, MARCH 2017. http://www.uconnruddcenter.org/files/Pdfs/Calculator%20Data_Methods_71917.pdf
Park S, Xu F, Town M, Blanck HM. Prevalence of Sugar-Sweetened Beverage Intake Among Adults–23 States and the District of Columbia, 2013. MMWR Morb Mortal Wkly Rep. 2016 Feb 26;65(7):169-74. doi: 10.15585/mmwr.mm6507a1.
Han E, Powell LM. Consumption patterns of sugar-sweetened beverages in the United States. Journal of the Academy of Nutrition and Dietetics. 2013;113(1):43-53.
Allcott H, Lockwood BB, Taubinsky D. Should We Tax Sugar-Sweetened Beverages? An Overview of Theory and Evidence. J Econ Perspect. 2019; 33 no 3: 202–27.
Krieger J, Bleich SN, Scarmo S, Ng SW. Sugar-Sweetened Beverage Reduction Policies: Progress and Promise. Annu Rev Public Health. 2021 Apr 1;42:439-461.
Lynn J. City Council votes to allocate ‘soda tax’ revenue to school district, city organizations. The Daily Californian. Jan. 20, 2016.
Friedman R. Public Opinion Data, 2013. New Haven, CT: Yale Rudd Center for Food Policy & Obesity; 2013.
Federal Trade Commission. A review of food marketing to children and adolescents: follow-up report. Washington, DC Dec 2012 2012.
Frieden TR, Mostashari F, Kerker BD, Miller N, Hajat A, Frankel M. Adult tobacco use levels after intensive tobacco control measures: New York City, 2002-2003. American Journal of Public Health. 2005;95(6):1016-1023.

Brief: Movement Breaks in the Classroom in Boston, MA

Posted on August 9, 2022

Teacher leading a movement break in the classroom with young kids

The information in this brief is intended only to provide educational information.

A version of this brief was published in May 2022. This brief was updated in August 2022 to reflect revised projections for Boston’s population.

This brief summarizes a CHOICES Learning Collaborative Partnership model examining a strategy to integrate movement breaks into school classrooms in Boston, MA. This strategy incorporates five-to-10-minute classroom physical activity breaks during class time in kindergarten to fifth grade classrooms.

The Issue

One in three first-graders in Boston has overweight or obesity.¹ Being physically active can support children in growing up at a healthy weight, though not all schools provide students with the recommended 150 minutes of physical activity per week or 30 minutes per day.^2,3 Regular physical activity can boost brain health, including improved cognition and reduced symptoms of depression.⁴ Students who are physically active also tend to have better grades, attendance at school, and stronger muscles and bones.⁴

Experts suggest that schools provide opportunities for classroom physical activity,⁵ but few schools offer it.⁶ Movement breaks supplement other critical school physical activity opportunities, like recess and physical education, and help children meet recommendations for physical activity.⁵ Providing all students with opportunities to be physically active will ensure more students are growing up at a healthy weight and ready to learn.

About the Movement Breaks in the Classroom Strategy

We can provide healthier opportunities for all children by initiating strategies with strong evidence for effectiveness. To implement the Movement Breaks strategy, teachers, Wellness Champions, and staff would receive training, equipment, and materials to incorporate short activity breaks in the classroom to help children move more.^7,8 Initiating strategies with strong evidence for effectiveness like Movement Breaks in the Classroom helps fulfill Boston Public School’s (BPS) Physical Education and Physical Activity Policy requirements for schools to offer physical activity opportunities during the school day.³ This strategy also aligns with BPS’ Whole School, Whole Community, Whole Child approach, which supports students’ holistic health by promoting positive classroom environments that foster physical activity and learning.

Comparing Costs and Outcomes

A CHOICES cost-effectiveness analysis compared the costs and outcomes over a 10-year time horizon (2020-2030) of implementing movement breaks with the costs and outcomes associated with not implementing them. We assumed that elementary schools in Boston Public Schools serving grades K-5 would receive training, equipment, and materials to implement movement breaks. The model assumes that 56% of those trained would implement the movement breaks in classrooms.

Implementing movement breaks in the classroom is an investment in the future. By the end of 2030:

Conclusions and Implications

If movement breaks were incorporated into classrooms, we project that over 10 years, 29,400 students would benefit. The students would increase their moderate-to-vigorous-physical activity levels by 25 minutes per school week, helping them meet wellness goals of 150 minutes of physical activity per week.³ This strategy would also prevent 37 cases of childhood obesity (in 2030) and save $35,300 in health care costs related to excess weight over 10 years. The average annual cost to implement this program in every public elementary school (Grades K-5) in Boston would be $1.74 per student, or just over $1,000 per school per year.

In addition to promoting a healthy weight, classroom physical activity benefits students in other important ways. By training and equipping over 600 teachers and other school staff yearly to incorporate movement breaks in the classroom, this strategy could help all Boston Public Schools cultivate a positive school climate and improve social emotional learning.⁹ Participation in movement breaks are associated with students spending more time on task,⁵ and teachers report that students are more engaged, supportive of each other, and responsive to teacher instructions after participating in a movement break.¹⁰

Childhood is a crucial period for developing healthy habits. Many preventive strategies can play a critical role in helping children establish healthy behaviors early on in life. Providing movement breaks in the classroom is an easy and relatively low-cost way to increase physical activity and support the overall health and wellness of all Boston students.

References

School Health Services, Department of Public Health. Results from the Body Mass Index Screening in Massachusetts Public School Districts, 2017. 2020:88. https://www.mass.gov/doc/the-status-of-childhood-weight-in-massachusetts-2017
Boston Public Schools, Health and Wellness Department. School Health Profiles [2018]: Boston, MA.
Boston Public Schools. Physical Education & Physical Activity Policy. 2020:8. Superintendent’s Circular. https://drive.google.com/file/d/1rSGwpFaa4LsPKxjhdsHxz2IaXg3ZFVtE/view?usp=embed_facebook
Centers for Disease Control and Prevention. The Association Between School-Based Physical Activity, Including Physical Education, and Academic Performance. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2020-04-21T09:02:35Z 2010.
The Community Preventive Services Task Force. Physical Activity: Classroom-based Physical Activity Break Interventions. The Community Guide. 2021:8.
Classroom Physical Activity. Centers for Disease Control and Prevention. Accessed Oct 8, 2021. https://www.cdc.gov/healthyschools/physicalactivity/classroom-pa.htm
Erwin HE, Beighle A, Morgan CF, Noland M. Effect of a low-cost, teacher-directed classroom intervention on elementary students’ physical activity. J Sch Health. 2011;81(8):455-461.
Murtagh E, Mulvihill M, Markey O. Bizzy Break! The effect of a classroom-based activity break on in-school physical activity levels of primary school children. Pediatr Exerc Sci. 2013;25(2):300-307.
School-Based Physical Activity Improves the Social and Emotional Climate for Learning. Centers for Disease Control and Prevention,. Accessed March 9, 2022. https://www.cdc.gov/healthyschools/school_based_pa_se_sel.htm
Campbell AL, Lassiter JW. Teacher perceptions of facilitators and barriers to implementing classroom physical activity breaks. J Educ Res. 2020;113(2):108-119

Suggested Citation:

Carter J, Greene J, Neeraja S, Bovenzi M, Sabir M, Carter S, Bolton AA, Barrett JL, Reiner JR, Cradock AL, Gortmaker SL. Boston, MA: Movement Breaks in the Classroom {Issue Brief}. Boston Public Schools, Boston Public Health Commission, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; August 2022. For more information, please visit www.choicesproject.org

A version of this brief was published in May 2022. This brief was updated in August 2022 to reflect revised projections for Boston’s population.

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the Boston Public Health Commission through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. This work is supported by 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.

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Brief: Home Visits to Reduce Screen Time in Boston, MA

Posted on May 31, 2022

Mom and daughter meeting with counselor at home, while daughter is looking at a handheld screen

The information in this brief is intended only to provide educational information.

A version of this brief was published in May 2022. This brief was updated in February 2023 to reflect revised projections for Boston’s population.

This brief summarizes a CHOICES Learning Collaborative Partnership model examining a strategy to reduce the amount of screen time viewed at home by young children in Boston, MA. Community health workers would provide counseling and resources on strategies to limit children’s screen time to children and families who participate in home visiting programs.

The Issue

In 2017, three in 10 first graders in Boston had overweight or obesity.¹ Access to healthy foods, beverages, and opportunities to participate in regular physical activity are key priorities for communities in supporting children growing up at a healthy weight. However, not all families have access to the same resources.

Limiting children’s screen time is also a high priority for communities.² Food companies use television to market unhealthy foods and drinks to children, which can increase children’s food intake and their risk for excess weight gain.³ Moreover, food companies have disproportionately marketed fast food and sugary drinks to Black and Hispanic youth⁴ and children from lower income households watch more screen media than their peers,⁵ putting them at greater risk for unfavorable health outcomes.

Helping families manage screen time can promote a healthy weight and advance health equity. Home visiting programs engage community health workers to improve health behaviors and reduce the risk of chronic diseases for families with children. Home visiting programs specifically support children who are exposed to conditions that could negatively impact their health.⁶

About the Home Visits to Reduce Screen Time Strategy

This strategy supports the Boston Public Health Commission’s goal of preventing obesity and chronic disease using a health equity lens while also building and maintaining partnerships with home visiting programs across Boston. Through professional development trainings opportunities, community health workers would learn ways to support families and children in limiting their screen time. During a home visit, community health workers would share the importance of appropriate screen time limits and provide strategies and tools for families to use, including a screen time management device. Integrating this strategy through existing home visiting programs could help more children manage their screen time and grow up at a healthy weight.⁷

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes over a 10-year time horizon (2020-2030) of implementing the home visits to limit screen time strategy with the costs and outcomes associated with not implementing the program.

Implementing the home visits to reduce screen time strategy is an investment in the future. By the end of 2030:

Conclusions and Implications

Incorporating counseling and providing resources to limit screen time through existing home visiting programs could reach 3,320 children ages 4-7. Over 10 years, we project that children whose families participated in the program would watch nearly two fewer hours of screen time per day, on average. This strategy could also prevent 60 cases of childhood obesity in 2030, saving $44,600 in health care costs related to excess weight over 10 years. It would cost $540 per child.

Community health workers play an important role in building healthier communities and promoting health equity. By training and equipping 119 community health workers annually by ensuring that everyone has access to what they need to grow up healthy and strong, this strategy could help reach those families and children that may be at higher risk of having or developing obesity. Children in households with low income could see greater health benefits from this strategy.⁷

In addition to promoting healthy weight, this strategy may also benefit children in other ways. Too much screen time can negatively impact children’s sleep and social wellbeing.⁸ Providing children and their families with strategies to move away from their screens allows for more time for developmentally appropriate activities like reading and active play. Strategies families can use to limit online video viewing and mobile device use may be particularly important as screen time from these sources has increased dramatically in recent years.⁵

Working with community health workers in Boston’s existing home visiting programs will help families build a foundation for overall health and wellbeing. These preventive strategies play a critical role in helping children establish healthy habits early on in life.

References

School Health Services, Dept of Public Health. Results from the Body Mass Index Screening in Massachusetts Public School Districts, 2017. School Health Services, Dept of Public Health; 2020. Accessed Feb 22, 2022. https://www.mass.gov/doc/the-status-of-childhood-weight-in-massachusetts-2017
Healthy People 2030: Building a healthier future for all. Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services. Accessed Feb 4, 2022. https://health.gov/healthypeople
Russell SJ, Croker H, Viner RM. The effect of screen advertising on children’s dietary intake: A systematic review and meta-analysis. Obes Rev. 2019;20(4):554-568. doi:10.1111/obr.12812
UConn Rudd Center for Food Policy & Obesity. Fast Food Advertising: Billions in spending, continued high exposure by youth. 2021. Fast Food Fact, UConn Rudd Center for Food Policy & Obesity. https://www.fastfoodmarketing.org/media/FACTS%20Summary%20FINAL%206.15.pdf
Rideout V, Robb MB. The Common Sense Census: Media Use by Kids Age Zero to Eight. 2020. Common Sense Census. https://www.commonsensemedia.org/research/the-common-sense-census-media-use-by-kids-age-zero-to-eight-2020
Duffee JH, Mendelsohn AL, Kuo AA, Legano LA, Earls MF. Early Childhood Home Visiting. Pediatrics. Sep 2017;140(3). doi:10.1542/peds.2017-2150
Epstein LH, Roemmich JN, Robinson JL, et al. A randomized trial of the effects of reducing television viewing and computer use on body mass index in young children. Arch Pediatr Adolesc Med. Mar 2008;162(3):239-45. doi:10.1001/archpediatrics.2007.45
Tremblay MS, LeBlanc AG, Kho ME, et al. Systematic review of sedentary behaviour and health indicators in school-aged children and youth. Int J Behav Nutr Phys Act. Sep 21 2011;8:98. doi:10.1186/1479-5868-8-98

Suggested Citation:

Carter S, Bovenzi M, Sabir M, Bolton AA, Reiner JR, Barrett JL, Cradock AL, Gortmaker SL. Boston, MA: Home Visits to Reduce Screen Time {Issue Brief}. Boston Public Health Commission, Boston, MA, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; February 2023. For more information, please visit www.choicesproject.org

A version of this brief was published in May 2022. This brief was updated in February 2023 to reflect revised projections for Boston’s population.

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

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Brief: Improving Drinking Water Equity and Access in California Schools

Posted on March 23, 2022

School-aged girl drinking water from a reusable water bottle

The information in this brief is intended only to provide educational information.

This brief summarizes a CHOICES Learning Collaborative Partnership model examining a strategy to improve access to drinking water in California schools. This voluntary water equity and access program involves the installation of touchless chilled water dispensers on or near school cafeteria lunch lines in K-8 non-charter California public schools that have adequate plumbing.

The Issue

All children should have access to clean, appealing, and free drinking water no matter where they live or where they go to school. Providing appealing access to drinking water gives students a healthier alternative to sugary drinks, like sweetened fruit drinks, sports drinks, and soda. Students drink more water when schools provide access to water at lunch at no charge,¹ and improving school water access can help kids grow up at a healthy weight.^2,3

In California, one in 10 schools reported having no access to free drinking water where meals are served despite state and federal requirements.^4,5 Additionally, only one in five schools reported meeting criteria considered the standard for excellence in water access.⁴ Creating a healthy, equitable school environment that includes appealing drinking water access can help set children up for a healthy future.

About the Water Dispensers in Schools Strategy

This strategy focuses on increasing water access by installing touchless water dispensers at schools serving primarily families with low income, which also have a greater share of Black/African American and Latino students than other schools in California. Promoting better drinking water access in schools has been shown to increase water intake during the day and may help promote a healthy weight.³ Thus, it is a strategy that can help local health departments reach the twin goals of increasing access to and promotion of safe drinking water while decreasing access to and consumption of sugary drinks.⁶ Putting this strategy into place would require resources for administering the program, installing and maintaining dispensers, utility and disposable cup usage, lead testing and remediation, and delivering water-promotion education.

Comparing Costs and Outcomes

Installation of touchless water dispensers in schools in California is an investment in a more equitable future. By the end of 2030:

Conclusions and Implications

Installing water dispensers in K-8 public schools is an effective strategy for increasing access to clean, appealing, and free drinking water. Over 10 years, this strategy is expected to improve drinking water access and consumption for over 1.8 million students in California. This strategy is estimated to prevent 3,660 cases of childhood obesity in 2030 and would cost on average $6 per child to implement each year. Comparatively, the value of lunch served to students is $3 per day or about $600 per year.⁷ While the costs to implement this strategy would be $21,500 per school over 10 years, there would be an estimated $12 million in obesity-related health care cost savings over the same time period.

Improving students’ access to free, clean drinking water could promote health equity. Latino youth report less availability of drinking water access in schools,⁸ and Black/African American youth are less likely to be adequately hydrated compared with White non-Latino youth.⁹ Focusing drinking water access improvements in schools with high percentages of Black/African American and Latino students may benefit these populations the most. In addition to promoting a healthy weight, this strategy may also benefit children in other ways. Adequate water consumption can lead to improvements in well-being and support cognitive function.¹⁰ Fluoridated water intake also prevents dental caries.¹¹

Though investment is required, every student deserves access to clean, appealing drinking water, and this strategy can be a part of a suite of interventions that support children and their families. Many preventive strategies play a critical role in helping children establish healthy habits early on in life. Focusing on supporting these healthy habits now can help more children grow up at a healthy weight.

References

Bogart LM, Babey SH, Patel AI, Want P, Schuster MA. Lunchtime school water availability and water consumption among California adolescents. Journal of Adolescent Health. 2016; 58(1):98-103, doi: 10.1016/j.jadohealth.2015.09.007.
Schwartz AE, Leardo M, Aneja S, Elbel B. Effect of a School-Based Water Intervention on Child Body Mass Index and Obesity. JAMA Pediatr. 2016; 170(3):220-226. doi:10.1001/jamapediatrics.2015.3778.
Kenney EL, Cradock AL, Long MW, et al. Cost-Effectiveness of Water Promotion Strategies in Schools for Preventing Childhood Obesity and Increasing Water Intake. Obesity. 2019;27(12):2037-2045.
Altman EA, Lee KL, Hecht CA, Hampton KE, Moreno G, Patel AI. Drinking water access in California schools: Room for improvement following implementation of school water policies. Preventive Medicine Reports. 2020;19:101143. Published 2020 Jun 8. doi:10.1016/j.pmedr.2020.101143.
California Department of Education. Drinking Water for Students in Schools. Reviewed January 14, 2020. https://www.cde.ca.gov/ls/nu/he/water.asp#:~:text=California%20Education%20Code%20Section%2038086%20states%20that%20if%20a%20school,reasons%20why%2C%20whether%20due%20to. Accessed February 16, 2021.
California Department of Public Health. FFY 2020-2022 SNAP-Ed Local Health Departments Programmatic Priorities. Published December 10, 2018. https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/NEOPB/CDPH%20Document%20Library/Branch16Add2FFY20-22SNAPEdLHD.pdf. Accessed January 29, 2021.
California Department of Education. 2019-20 CNP Reimbursement Rates. https://www.cde.ca.gov/ls/nu/rs/rates1920.asp. Accessed December 12, 2020.
Onfurak SJ, Park S, Wilking C. Student-reported school drinking fountain availability by youth characteristics and state plumbing codes. Preventing Chronic Disease. 2014; 11: E60, doi: 10.5888/pcd11.130314.
Kenney EL, Long MW, Cradock AL, Gortmaker SL. Prevalence of inadequate hydration among U.S. children and disparities by gender and race/ethnicity: National Health and Nutrition Examination Survey, 2009–2012. American Journal of Public Health. 2015; 105(8): e113-8, doi: 10.2105/AJPH.2015.302572.
Popkin BM, D’Anci KE, Rosenberg IH. Water, hydration, and health. Nutition Reviews. 2010 Aug;68(8):439-58.
American Dental Association and Centers for Disease Control. Nature’s Way to Prevent Tooth Decay: Water Fluoridation. Published 2006. https://www.cdc.gov/fluoridation/pdf/natures_way.pdf. Accessed July 13, 2021.

Suggested Citation:

Gouck J, Whetstone L, Walter C, Pugliese J, Kurtz C, Seavey-Hultquist J, Barrett J, McCulloch S, Reiner J, Cradock AL. California: Improving Drinking Water Equity and Access in California Schools {Issue Brief}. California Department of Public Health, Sacramento, CA, the County of Santa Clara Public Health Department, San Jose, CA, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; December 2021. For more information, please visit www.choicesproject.org

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the California Department of Public Health and the County of Santa Clara Public Health Department through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. This work is supported by 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.

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CHOICES Discussion Paper: Cost-Effective Strategies to Prevent Obesity & Improve Health Equity

Posted on January 13, 2022

The information in this discussion paper is intended only to provide educational information.

Abstract

We face growing prevalence of children and adults with obesity in the United States, and widening disparities by race, ethnicity, geography, and income. This growth is driven by many forces, including the marketing of foods and beverages that increase obesity risk as well as deeply rooted social and economic determinants and structural racism. This discussion paper is designed to help public health professionals and community members identify feasible and cost-effective intervention strategies that can prevent future obesity cases among children while improving health equity. We provide examples of such strategies in localities throughout the United States. We build on previous findings in CHOICES briefs that describe how Learning Collaborative Partnerships with health departments and their community partners, together with the CHOICES team, have assessed the future impact of a range of strategies on cases of obesity prevented and health equity. In all cases, the strategies have strong evidence for effectiveness and include: sugary drink excise taxes in Denver, Hawaii, California, and West Virginia; a clinical strategy to treat children with obesity in Denver; an intervention to reduce excess TV viewing in Oklahoma. Projections are made using the CHOICES microsimulation model, taking into account effectiveness of the intervention, expected reach in the population, evidence for intervention cost, and other relevant local data. Definitions of groups experiencing disadvantage and inequities were developed with local decision-makers and community members. Projected effectiveness is expressed as cases of obesity prevented, and improvements in health equity as changes in risk relative to a reference population. These examples describe feasible and cost-effective strategies that can prevent future obesity cases and improve health equity.

Continue reading in the full discussion paper.

Suggested Citation

Gortmaker SL, Bleich SN, Kenney EL, Barrett JL, Ward ZJ, Long MW, Cradock AL. Cost-Effective Strategies to Prevent Obesity and Improve Health Equity. Harvard T. H. Chan School of Public Health, 2021. For further information, contact choicesproject@hsph.harvard.edu and visit www.choicesproject.org

Funding

Funded by The JPB Foundation (Grant No. 1085), the National Institutes of Health (Grant No. R01HL146625) and the Centers for Disease Control and Prevention (CDC) (Grant No. U48DP006376). This work is solely the responsibility of the authors and does not represent official views of the CDC, the NIH, or other agencies.

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Report: New York State: Sugary & Diet Drink Taxes

Posted on November 18, 2021

The information in this report is intended to provide educational information on the cost-effectiveness of sugary drink excise taxes.

Executive Summary

High rates of obesity are one of the greatest public health threats facing the United States. Sugary drink consumption can lead to type 2 diabetes, heart disease, cavities, weight gain, and obesity. Overweight and obesity are linked to many chronic conditions such as high blood pressure and some cancers.

The current public health landscape demonstrates that nutrition remains critical, even during an infectious disease outbreak like COVID-19. Health conditions such as obesity, diabetes, and heart disease are related to nutrition and can increase the risk of severe illness from COVID-19. Rates of these chronic diseases are still too high in New York state, disproportionately burdening communities of color.

Federal, state, and local governments have long considered implementing excise taxes on sugary drinks to reduce consumption, reduce obesity, and provide an additional source of government revenue.^1-4As of 2019, seven U.S. jurisdictions are enforcing beverage tax policies.

We modeled implementation of a state excise tax using two scenarios. Scenario one included a tax on sugary drinks only and scenario two included a tax on both sugary and diet drinks. Each scenario examined three potential tax rates: $0.01/ounce, $0.015/ounce, and $0.02/ounce.

All six tax models resulted in lower levels of sugary drink consumption, thousands of people for whom obesity would be prevented (note: referred to as “cases” throughout this report), improved health equity, and hundreds of millions of dollars in health care cost savings. The estimated effects of the interventions on health care costs were based on national analyses that indicated excess health care costs associated with obesity among children and adults.⁵Health care cost savings per dollar invested ranged from $22.40 to $57.40 across the six models. Projections demonstrate that annual revenue generated from a sugary drink tax is likely substantial.

Continue reading in the full report.

Contact choicesproject@hsph.harvard.edu for an accessible version of this report.

Citation

Gortmaker SL, Long MW, Ward ZJ, Giles CM, Barrett JL, Resch SC, Greatsinger A, Garrone ME, Tao H, Flax CN, Cradock AL. New York State: Sugary & Diet Drink Taxes. The CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; November 2021. For more information, please visit www.choicesproject.org.

The design for this brief and its graphics were developed by Molly Garrone, MA.

Funding

This work is supported by the New York City Department of Health and Mental Hygiene and The JPB Foundation. The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the funders.

For further information, contact choicesproject@hsph.harvard.edu

References

American Public Health Association. Taxes on Sugar-Sweetened Beverages. 2012.
Hakim D and Confessore N. Paterson seeks huge cuts and $1 billion in taxes and fees. The New York Times, Jan 19, 2010.
Falbe J, Rojas N, Grummon AH, Madsen KA. Higher Retail Prices of Sugar-Sweetened Beverages 3 Months After Implementation of an Excise Tax in Berkeley, California. Am J Public Health. 2015 Nov;105(11):2194-201.
Leonhardt D. The battle over taxing soda. The New York Times, May 19, 2010.
Finkelstein EA, Trogdon JG. Public health interventions for addressing childhood overweight: Analysis of the business case. Am J Public Health. 2008;98(3):411-5.

See the report for the full list of references.

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Report: New York City: Sugary & Diet Drink Taxes

Posted on November 18, 2021

The information in this report is intended to provide educational information on the cost-effectiveness of sugary drink excise taxes.

Executive Summary

The current public health landscape demonstrates that nutrition remains critical, even during an infectious disease outbreak like COVID-19. Health conditions such as obesity, diabetes, and heart disease are related to nutrition and can increase the risk of severe illness from COVID-19. Rates of these chronic diseases are still too high in New York City (NYC), disproportionately burdening communities of color.

We modeled implementation of a city excise tax using two scenarios. Scenario one included a tax on sugary drinks only and scenario two included a tax on both sugary and diet drinks. Each scenario examined three potential tax rates: $0.01/ounce, $0.015/ounce, and $0.02/ounce.

All six tax models resulted in lower levels of sugary drink consumption, thousands of people for whom obesity would be prevented (note: referred to as “cases” throughout this report), improved health equity, and hundreds of millions of dollars in health care cost savings. The estimated effects of the interventions on health care costs were based on national analyses that indicated excess health care costs associated with obesity among children and adults.⁵Health care cost savings per dollar invested ranged from $12.80 to $32.90 across the six models. Projections demonstrate that annual revenue generated from a sugary drink tax is likely substantial.

Continue reading in the full report.

Contact choicesproject@hsph.harvard.edu for an accessible version of this report.

Citation

Gortmaker SL, Long MW, Ward ZJ, Giles CM, Barrett JL, Resch SC, Greatsinger A, Garrone ME, Tao H, Flax CN, Cradock AL. New York City: Sugary & Diet Drink Taxes. The CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; November 2021. For more information, please visit www.choicesproject.org.

The design for this brief and its graphics were developed by Molly Garrone, MA.

Funding

For further information, contact choicesproject@hsph.harvard.edu

References

American Public Health Association. Taxes on Sugar-Sweetened Beverages. 2012.
Hakim D and Confessore N. Paterson seeks huge cuts and $1 billion in taxes and fees. The New York Times, Jan 19, 2010.
Falbe J, Rojas N, Grummon AH, Madsen KA. Higher Retail Prices of Sugar-Sweetened Beverages 3 Months After Implementation of an Excise Tax in Berkeley, California. Am J Public Health. 2015 Nov;105(11):2194-201.
Leonhardt D. The battle over taxing soda. The New York Times, May 19, 2010.
Finkelstein EA, Trogdon JG. Public health interventions for addressing childhood overweight: Analysis of the business case. Am J Public Health. 2008;98(3):411-5.

See the report for the full list of references.

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Brief: More Movement Program in Early Child Care Settings in Boston, MA

Posted on September 20, 2021

The information in this brief is intended only to provide educational information.

Versions of this brief were published in September 2021 and January 2023. The January 2023 update was to reflect revised projections for Boston’s population. This brief was updated again in October 2023 to more accurately represent the model period.

This brief summarizes a CHOICES Learning Collaborative Partnership model examining the More Movement program in early child care settings in Boston. This strategy provides training opportunities and resources for early child care educators to implement actions in their programs to encourage physical activity.

The Issue

Every child should have opportunities to grow up at a healthy weight. Early child care programs are key settings that can provide physical activity opportunities that support child development and lay the foundation for a healthy lifestyle. National guidelines recommend preschool-aged children engage daily in 60 to 90 minutes of moderate-to-vigorous physical activity while in early child care settings.¹ However, many children do not meet these recommended levels of activity.²

In 2017, about three in 10 first graders in Boston had overweight or obesity.³ If trends continue, over half of today’s children will have obesity as adults.⁴ Increasing physical activity in child care settings is a national health priority.⁵ Therefore, identifying strategies that help young children move more is important for ensuring children develop healthy habits and grow up at a healthy weight.

About the More Movement Program in Early Child Care Settings

The More Movement program could support Boston’s efforts to improve early child care quality through the Boston Healthy Child Care Initiative. It would include training opportunities for early child care educators in physical activity curricula, provide resources and instructional materials, and support technical assistance opportunities that may lead to higher physical activity levels among young children.^6,7 Helping educators implement practices shown to be effective in increasing physical activity can help the children in Boston’s early education and care settings to move more.

NOTE: The data that informed these estimates were collected after the program closures prompted by the COVID-19 pandemic. As programs reopen and demand continues to increase, this strategy could reach more children.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of implementing the More Movement program in Boston early child care settings with the costs and outcomes associated with not implementing the strategy over 10 years (2020-2029).

Implementing the More Movement program in early child care settings is an investment in the future. By the end of 2029:

Conclusions and Implications

If the More Movement program were implemented, we project that over 10 years, 18,200 children ages 3-5 would attend early child care programs that promote and encourage more physical activity (based on the number of programs open during the COVID-19 pandemic). This strategy would prevent 94 cases of obesity in 2029 alone, saving $104,000 in obesity-related health care costs over 10 years. The average annual cost to implement these activities would be $293 per program, or $30 per child.

Expanding training opportunities for early child care educators will also help support quality care. Ensuring access to quality care is essential for families and employers.⁸ In the initial training series, the More Movement program would provide additional skills training and professional development for 1,380 educators and more physical activity promotion opportunities in 570 (100%) child care programs serving 3-5 year olds.

Besides promoting a healthy weight, engaging in physical activity benefits children in other ways. Increased physical activity is linked to improved bone and muscular health and better gross motor skills in young children.^9-11 We estimate that, on average, each child attending a More Movement program would increase daily moderate-to-vigorous physical activity by seven minutes. This can help to form a strong foundation for overall health and well-being.

The More Movement program is a strategy for training and providing technical assistance in early child care. As programs reopen post-pandemic and demand for child care continues to increase, the strategy could reach even more children. The More Movement program would enable early child care programs in Boston to support healthy growth because every child deserves a healthy start.

References

American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. Caring for our Children: National Health and Safety Performance Standards Guidelines for Early Care and Education Programs. 2019. https://nrckids.org/files/CFOC4%20pdf-%20FINAL.pdf
Tassitano RM, Weaver RG, Tenório MCM, Brazendale K, Beets MW. Physical activity and sedentary time of youth in structured settings: a systematic review and meta-analysis. International Journal of Behavioral Nutrition and Physical Activity. 2020;17(1):160. Published 2020 Dec 4. doi:10.1186/s12966-020-01054-y
School Health Services, Dept of Public Health. Results from the Body Mass Index Screening in Massachusetts Public School Districts, 2017. School Health Services, Dept of Public Health; 2020. Accessed July 23, 2021. https://www.mass.gov/doc/the-status-of-childhood-weight-in-massachusetts-2017
Ward Z, Long M, Resch S, Giles C, Cradock A, Gortmaker S. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. New England Journal of Medicine. 2017; 377(22): 2145-2153.
Healthy People 2030. Increase the proportion of child care centers where children aged 3 to 5 years do at least 60 minutes of physical activity a day — PA-R01. Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health. Accessed Nov 16, 2020. https://health.gov/healthypeople/objectives-and-data/browse-objectives/physical-activity/increase-proportion-child-care-centers-where-children-aged-3-5-years-do-least-60-minutes-physical-activity-day-pa-r01
Fitzgibbon ML, Stolley MR, Schiffer LA, et al. Hip-Hop to Health Jr. Obesity Prevention Effectiveness Trial: Postintervention Results. Obesity (Silver Spring). 2011;19(5):994-1003.
Kong A, Buscemi J, Stolley MR, Schiffer LA, Kim Y, Braunschweig CL, Gomez-Perez SL, Blumstein LB, Van Horn L, Dyer AR, Fitzgibbon ML. Hip-Hop to Health Jr. Randomized Effectiveness Trial: 1-Year Follow-up Results. American Journal of Preventive Medicine. 2016 Feb;50(2):136-44.
Campbell F, Patil P, McSwain K. Boston’s Child-Care Supply Crisis: What a Pandemic Reveals. Boston Opportunity Agenda; 2020. Accessed July 23, 2021. https://www.bostonopportunityagenda.org/-/media/boa/early-ed-census-2020-pt-1-202011.pdf
U.S. Dept of Health and Human Services. Physical Activity Guidelines for Americans, 2^nd edition. U.S. Dept of Health and Human Services; 2018. Accessed Jul 23, 2021. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf
Pate RR, Hillman CH, Janz KF, et al. Physical Activity and Health in Children Younger than 6 Years: A Systematic Review. Medicine & Science in Sports & Exercise. 06 2019;51(6):1282-1291.
Timmons BW, Leblanc AG, Carson V, et al. Systematic review of physical activity and health in the early years (aged 0-4 years). Applied Physiology, Nutrition, and Metabolism. Aug 2012;37(4):773-92.

Suggested Citation:

Bovenzi M, Carter S, Sabir M, Bolton AA, Barrett JL, Reiner JF, Cradock AL, Gortmaker SL. Boston, MA: More Movement Program in Early Child Care Settings {Issue Brief}. Boston Public Health Commission and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; October 2023. For more information, please visit www.choicesproject.org

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

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The Issue

About the Water Dispensers in Schools Strategy

Comparing Costs and Outcomes

Conclusions and Implications

References

Suggested Citation:

The Issue

About the Movement Breaks in the Classroom Strategy

Comparing Costs and Outcomes

Conclusions and Implications

References

Suggested Citation:

Executive Summary

Background

Modeling Framework: How excise taxes can lead to better health

Key Terms

How does an excise tax work?

Reach

Cost

CHOICES Microsimulation Model

Results: $0.02/ounce State Excise Tax on Sugary Drinks

Results: $0.02/ounce State Excise Tax on Sugary Drinks By Race/Ethnicity Groups

Communities of color make up:

Impact on Diabetes

Impact on Tooth Decay

Potential Yearly Sugary Drink Tax Revenue from a $0.02/ounce Sugary Drink Tax

Considerations for Health Equity

Implementation Considerations

Conclusion

Suggested Citation:

References

The Issue

About the Movement Breaks in the Classroom Strategy

Comparing Costs and Outcomes

Conclusions and Implications

References

Suggested Citation:

The Issue

About the Home Visits to Reduce Screen Time Strategy

Comparing Costs and Outcomes

Conclusions and Implications

References

Suggested Citation:

The Issue

About the Water Dispensers in Schools Strategy

Comparing Costs and Outcomes

Conclusions and Implications

References

Suggested Citation:

Abstract

Suggested Citation

Funding

Executive Summary

Citation

Funding

References

Executive Summary

Citation

Funding

References

The Issue

About the More Movement Program in Early Child Care Settings

Comparing Costs and Outcomes

Conclusions and Implications

References

Suggested Citation:

Resources

Results: ^$0.02/ounce State Excise Tax on Sugary Drinks By Race/Ethnicity Groups

Potential Yearly Sugary Drink Tax Revenue from a ^$0.02/ounce Sugary Drink Tax