Resource Type: Peer-Reviewed Publications

Cost-effectiveness and health equity improvements from excluding sugar-sweetened beverages from the Supplemental Nutrition Assistance Program

Posted on September 8, 2025

This study estimates the cost-effectiveness of excluding sugar-sweetened beverages from eligible purchases in the Supplemental Nutrition Assistance Program and its potential impact on health equity.

Musicus AA, Barrett JL, McCulloch SM, Long MW, Ward ZJ, Cradock AL, Bleich SN, Gortmaker SL. Cost-effectiveness and health equity improvements from excluding sugar-sweetened beverages from the Supplemental Nutrition Assistance Program. Am J Prev Med. 2025, In press. doi:10.1016/j.amepre.2025.108082. Epub 2025 Sep 8.

Abstract

Background

Although interventions to change nutrition policies, systems, and environments (PSE) for children are generally cost effective for preventing childhood obesity, existing evidence suggests that nutrition education curricula, without accompanying PSE changes, are more commonly implemented.

Introduction

Excluding sugar-sweetened beverages (SSBs) from eligible purchases in the Supplemental Nutrition Assistance Program (SNAP) has been proposed as a strategy to improve diet quality and health. This study estimates the cost-effectiveness of this policy and its potential impact on health equity.

Methods

The Childhood Obesity Intervention Cost Effectiveness Study (CHOICES) microsimulation and systematic review process was used in 2024 to estimate the potential impact of excluding SSBs from SNAP-eligible purchases over a ten-year period (2023-2032) for the U.S. population. Health outcomes related to excess weight, costs, and relative changes in obesity prevalence by income, race, and ethnicity group in 2032 were estimated.

Results

The policy is projected to be cost-saving, prevent 279,000 cases of obesity (95% UI: 149,000−446,000), and contribute 115,000 (95% UI: 60,100−187,000) quality-adjusted life years gained over ten years among SNAP participants. The policy could save an estimated $2.75 billion in healthcare costs related to excess weight over ten years, resulting in $3.35 in healthcare cost savings per dollar spent on implementation. Reductions in obesity prevalence were estimated to be 3.5 times greater among individuals with income ≤130% of the federal poverty level compared to the overall mean, and 3-3.5 times greater among non-Hispanic Black and Hispanic individuals compared to non-Hispanic white individuals.

Conclusions
Excluding SSBs from SNAP-eligible purchases could be a cost-saving strategy to improve health and health equity between income, racial, and ethnic groups. The U.S. Department of Agriculture could use pilot studies to test the real-world effects of excluding SSBs from SNAP.

Keywords
health equity; cost-effectiveness; Supplemental Nutrition Assistance Program; nutrition policy; sugar-sweetened beverages

Funding

Research reported in this publication was supported by the National Heart, Lung, and Blood Institute under Award Number R01HL146625, the Centers for Disease Control and Prevention under Award Number U48DP006376, and The JPB Foundation. Dr. Musicus’ time on this work was supported by NIH grants T32CA057711 and T32HL098048. The content of this paper is solely the responsibility of the authors and does not necessarily represent the represent the official views of the Centers for Disease Control and Prevention or any of the other funders. The funders had no role in the study design; collection, analysis, and interpretation of data; writing of the report; and the decision to submit the report for publication. Dr. Musicus is also affiliated with the Center for Science in the Public Interest (CSPI), but this work was completed entirely within her Harvard affiliation and does not reflect the views of CSPI. No financial disclosures were reported by the authors of this paper.

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Cost-Effectiveness of Installing Water Dispensers in Massachusetts’ Schools to Improve Nutrition Environments, Health, and Health Equity

Posted on May 19, 2025

This study estimates estimates reach, cost, cost-effectiveness, and impact on weight status and obesity-related health equity of a strategy to install chilled, filtered water dispensers on school lunch lines in Massachusetts’ schools.

AL, Barrett JL, McCulloch SM, Good N, Santarelli C, Bolton AA, Reiner JF, Ward ZJ, Gortmaker SL. Cost-Effectiveness of Installing Water Dispensers in Massachusetts’ Schools to Improve Nutrition Environments, Health, and Health Equity. J Acad Nutr Diet. 2025 May 19:S2212-2672(25)00167-4. doi: 10.1016/j.jand.2025.05.008. Epub ahead of print. PMID: 40398534.

Abstract

Background

Evidence suggests that providing children with water on school lunch lines promotes healthy weight and is cost-effective.

Objective

Estimate reach, cost, cost-effectiveness, and impact on weight status and obesity-related health equity of a strategy to install chilled, filtered water dispensers on school lunch lines in Massachusetts’ schools.

Design

A cost-effectiveness analysis was conducted in 2022-2023 using the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) microsimulation model (2020-2029), estimates from published studies, publicly available national and state surveillance, programmatic, administrative data, and experts’ assumptions.

Participants/setting

Schools participating in Massachusetts’ school drinking water lead testing program with elevated lead concentrations in areas with disproportionate health risks MAIN OUTCOME MEASURES: Reach, cost, cost per quality-adjusted life year (QALY) gained, and cases of obesity prevented overall and by income, race, and ethnicity STATISTICAL ANALYSES: Means and 95% uncertainty intervals (UIs) for outcomes were estimated by running the model 1000 times, accounting for uncertainty from data sources and population projections.

Results

This strategy is projected to improve drinking water access for 265 000 (95% UI, 259 000-273 000) students in 304 schools, prevent 525 (95% UI, 192-880) cases of childhood obesity in 2029, cost $4.48/student/year (95% UI, $3.54-$5.43) to implement, and is likely cost-effective ($72 700 (95% UI, $40 000-$234 000) per QALY). Larger projected reductions in obesity prevalence for Hispanic/Latino and Black students compared with white students were observed (7.2 [95% UI, 5.2-10.3], and 4.7 [95% UI, 2.9-7.4], respectively), and among students from families with lowest incomes (<130% Federal Poverty Level) compared with the highest incomes (>350% Federal Poverty Level) (2.6 [95% UI, 1.9-3.5]).

Conclusions

A strategy to provide chilled, filtered water dispensers on lunch lines in Massachusetts schools is projected to improve school nutrition environments, increase water consumption, prevent excess weight gain, improve health equity, and be cost-effective.

Keywords: Cafeteria; Hydration; Lead; Obesity; Water filter.

Funding

This work was supported by a grant from the Centers for Disease Control and Prevention (U48DP006376), and by grants from the National Heart, Lung and Blood Institute at the National Institutes of Health (R01HL14662501) and The JPB Foundation. SL Gortmaker was also supported by an anonymous donation in memory of Melvin R. Seiden. The anonymous donor had no role in the design, analysis, or writing of this article. 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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School-based nutrition education programs alone are not cost effective for preventing childhood obesity: a microsimulation study

Posted on January 23, 2025

This study aims to estimate the societal costs and potential for cost-effectiveness of 3 nutrition education curricula frequently implemented in United States public schools for childhood obesity prevention.

Kenney EL, Poole MK, McCulloch SM, Barrett JL, Tucker K, Ward ZJ, Gortmaker SL. School-based nutrition education programs alone are not cost effective for preventing childhood obesity: a microsimulation study. Am J Clin Nutr. 2025 Jan;121(1):167-173. doi: 10.1016/j.ajcnut.2024.11.006. Epub 2024 Nov 12.

Abstract

Background

Objectives

This study aimed to estimate the societal costs and potential for cost-effectiveness of 3 nutrition education curricula frequently implemented in United States public schools for childhood obesity prevention.

Methods

In 2021, we searched for nutrition education curricula in the Supplemental Nutrition Assistance Program (SNAP)-Ed Toolkit, a catalog of interventions for obesity prevention coordinated by the federal government. Standard costing methodologies estimated the societal costs from 2023 to 2032 of nationwide implementation of each identified curriculum. Using the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) microsimulation model, which projects the costs, health care costs saved, and cases of obesity prevented for childhood obesity prevention interventions, we conducted threshold analyses for each curriculum, estimating the cost per quality-adjusted life-year for a range of hypothetical effects on child BMI to determine how large of an effect each curriculum would need to have to meet a cost-effectiveness threshold of $150,000 per quality-adjusted life-year.

Results

Three nutrition education curricula without PSE were identified from SNAP-Ed; none had evidence of an impact on obesity risk. From 2023 to 2032, the estimated implementation costs of the curricula nationwide ranged from $1.80 billion (95% upper interval: $1.79, $1.82 billion) to $3.48 billion (95% upper interval: $3.44, $3.51 billion). Each curriculum would have to reduce average child BMI by 0.10 kg/m2 or more—an effect size that has not been reported by any of the 3 curricula, or by more comprehensive existing prevention programs—to be considered cost effective at this threshold.

Conclusions
SNAP-Ed–endorsed nutrition education curricula alone are unlikely to be cost effective for preventing childhood obesity. Continued efforts to implement interventions with strong evidence for effectiveness, including PSE approaches, are needed.

Keywords
childhood obesity; nutrition education; schools; prevention; cost-effectiveness analysis; threshold analysis

Funding

This study was supported by Healthy Eating Research, a national program of the Robert Wood Johnson Foundation (2833590), The JPB Foundation, the National Heart, Lung, and Blood Institute (NHLBI) (5T32HL098048, R01HL146625, and 1F31HL162250), the National Institute of Diabetes and Digestive and Kidney Diseases (K01DK125278), and the Centers for Disease Control and Prevention (U48DP006376). The content is solely the responsibility of the authors and does not necessarily represent the official views of these agencies.

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Cost-effectiveness of mandating calorie labels on prepared foods in supermarkets

Posted on October 17, 2024

This study determines the cost-effectiveness of the requirement for chain food establishments—including supermarkets—to display calorie labels on prepared (i.e., ready-to-eat) foods since 2018.

Grummon AH, Barrett JL, Block JP, McCulloch S, Bolton A, Dupuis R, Petimar J, Gortmaker SL. Cost-effectiveness of mandating calorie labels on prepared foods in supermarkets. Am J Prev Med. 2024 Oct, doi: 10.1016/j.amepre.2024.10.007.

Abstract

Introduction

The US has required chain food establishments—including supermarkets—to display calorie labels on prepared (i.e., ready-to-eat) foods since 2018. Implementation of this supermarket calorie labeling policy reduced purchases of prepared foods from supermarkets, but it remains unknown whether the policy is cost-effective.

Methods

In 2023-2024, this study applied the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) microsimulation model to estimate the effects of the supermarket calorie labeling policy on health, costs, and cost-effectiveness over 10 years (2018-2027) for the US population. The model projected benefits overall and among racial, ethnic, and income subgroups. Sensitivity analyses varied assumptions about the extent to which consumers replace calorie reductions from prepared foods with calories from other sources (i.e., caloric compensation).

Results

From 2018-2027, the supermarket calorie labeling policy was projected to save $348 million in healthcare costs (95% Uncertainty Interval [UI]: $263-426 million), prevent 21,700 cases of obesity (95% UI: 18,200-25,400), including 3,890 cases of childhood obesity (95% UI: 2,680-5,120), and lead to 15,100 quality-adjusted life years (QALYs) gained across the US population (95% UI: 10,900-20,500). The policy was projected to prevent cases of obesity and childhood obesity across all racial, ethnic, and income groups. The policy was projected to be cost-saving when assuming low and moderate caloric compensation and cost-effective when assuming very high caloric compensation.

Conclusions

A policy requiring calorie labels on prepared foods in supermarkets was projected to be cost-saving or cost-effective and lead to reductions in obesity across all racial, ethnic, and income groups.

Keywords
calorie labels; food policy; cost-effectiveness; obesity; simulation

Funding

This research was supported in part by a grant from the National Institutes of Health (NIH) National Institute of Diabetes and Digestive and Kidney Diseases to Jason P. Block (R01 DK115492) and the NIH National Heart, Lung and Blood Institute at the National Institutes of Health (R01 HL14662501), the JPB Foundation (Grant no 1085) and the Centers for Disease Control and Prevention (CDC, U48 DP006376). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH, JPB Foundation, or CDC. The funders had no role in the study design; collection, analysis, or interpretation of the data; writing the manuscript; or the decision to submit the paper for publication.

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Association of continuous BMI with health-related quality of life in the United States by age and sex

Posted on October 7, 2024

This study estimates health-related quality of life by continuous BMI by age, sex, and demographic group in the United States.

Ward ZJ, Dupuis R, Long MW, Gortmaker SL. Association of continuous BMI with health-related quality of life in the United States by age and sex. Obesity (Silver Spring). 2024 Nov. doi: 10.1002/oby.24141. PMID: 39370765.

Abstract

Objective

The objective of this study is to estimate health-related quality of life (HRQoL) by continuous BMI by age, sex, and demographic group in the United States.

Methods

We estimated HRQoL (overall and by domain) by continuous BMI using SF-6D (Short-Form Six-Dimension) data from 182,778 respondents ages 18 years and older from the repeated cross-sectional Medical Expenditure Panel Survey (MEPS) 2008 to 2016. We adjusted for BMI self-report bias and for potential confounding between BMI and HRQoL.

Results

We found an inverse J-shaped curve of HRQoL by BMI, with lower values for female individuals and the highest health utilities occurring at BMI of 20.4 kg/m² (95% CI: 20.32-20.48) for female individuals and 26.5 kg/m² (95% CI: 26.45-26.55) for male individuals. By BMI category, excess weight contributed to HRQoL loss of 0.0349 for obesity overall, rising to 0.0724 for class III obesity. By domain, pain was the largest cause of HRQoL loss for obesity (26%), followed by role limitations (22%).

Conclusions

HRQoL is lower for people with excess body weight across a broad range of ages and BMI levels, especially at high levels of BMI, with pain being the largest driver of HRQoL loss. These findings highlight the importance of promoting a healthy weight for the entire population while also targeting efforts to prevent extreme weight gain over the life course.

Funding

All of the authors received support from The JPB Foundation (grant no. 1085). Zachary Ward and Steven Gortmaker were supported by the National Institutes of Health (grant no. R01HL146625). StevenGortmaker was supported by the Centers for Disease Control andPrevention (CDC; grant no. U48DP006376). This work is solely the responsibility of the authors and does not represent official views of the CDC or other funders.

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Cost-Effectiveness of a Primary Care-Based Healthy Weight Clinic Compared with Usual Care

Posted on August 28, 2024

This study determines the cost-effectiveness of implementing the Healthy Weight Clinic, a primary care-based intervention for 6- to 12-year-old children with overweight or obesity, at federally qualified health centers nationally.

Sharifi M, Fiechtner LG, Barrett JL, O’Connor G, Perkins M, Reiner JF, Luo M, Taveras EM, Gortmaker SL. Cost-effectiveness of a primary care-based Healthy Weight Clinic compared with usual care. Obesity. 2024 Sep;32(9):1734-1744. doi: 10.1002/oby.24111.

Abstract

Objective

The objective of this study was to project the cost-effectiveness of implementing the Healthy Weight Clinic (HWC), a primary care-based intervention for 6- to 12-year-old children with overweight or obesity, at federally qualified health centers (FQHCs) nationally.

Methods

We estimated intervention costs from a health care sector and societal perspective and used BMI change estimates from the HWC trial. Our microsimulation of national HWC implementation among all FQHCs from 2023 to 2032 estimated cost per child and per quality-adjusted life year (QALY) gained and projected impact on obesity prevalence by race and ethnicity. Probabilistic sensitivity analyses assessed uncertainty around estimates.

Results

National implementation is projected to reach 888,000 children over 10 years, with a mean intervention cost of $456 (95% uncertainty interval [UI]: $409–$506) per child to the health care sector and $211 (95% UI: $175–$251) to families (e.g., time participating). Assuming effect maintenance, national implementation could result in 2070 (95% UI: 859–3220) QALYs gained and save $14.6 million (95% UI: $5.6–$23.5 million) in health care costs over 10 years, yielding a net cost of $278,000 (95% CI: $177,000–$679,000) per QALY gained. We project greater reductions in obesity prevalence among Hispanic/Latino and Black versus White populations.

Conclusions

The HWC is relatively low-cost per child and projected to reduce obesity disparities if implemented nationally in FQHCs.

Funding

National Heart, Lung, and Blood Institute, Grant/Award Numbers: R01HL151603, K24HL159680, R01HL146625; National Institute on Minority Health and Health Disparities, Grant/Award Number: R01MD014853; Agency for Healthcare Research and Quality, Grant/Award Number: K08HS024332; Eunice Kennedy Shriver National Institute of Child Health and Human Development, Grant/Award Number: K23HD090222; National Center for Chronic Disease Prevention and Health Promotion, Grant/Award Numbers: U18DP006259, U48DP006376; National Institute of Diabetes and Digestive and Kidney Diseases, Grant/Award Number: K24DK105989; The JPB Foundation, Grant/Award Number: 1085.

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Cost-effectiveness of Improved WIC Food Package for Preventing Childhood Obesity

Posted on January 23, 2024

This study determines the cost-effectiveness of changes to WIC’s nutrition standards in 2009 for preventing obesity and to estimate impacts on socioeconomic and racial/ethnic inequities.

Kenney EL, Lee MM, Barrett JL, Ward ZJ, Long MW, Cradock AL, Williams DR, Gortmaker SL. Cost-effectiveness of Improved WIC Food Package for Preventing Childhood Obesity. Pediatrics. 2024 Jan;153. doi: 10.1542/peds.2023-063182.

Abstract

Background & Objectives

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) prevents food insecurity and supports nutrition for more than 3 million low-income young children. Our objectives were to determine the cost-effectiveness of changes to WIC’s nutrition standards in 2009 for preventing obesity and to estimate impacts on socioeconomic and racial/ethnic inequities.

Methods

We conducted a cost-effectiveness analysis to estimate impacts from 2010 through 2019 of the 2009 WIC food package change on obesity risk for children aged 2 to 4 years participating in WIC. Microsimulation models estimated the cases of obesity prevented in 2019 and costs per quality-adjusted-life year gained.

Results

An estimated 14.0 million 2- to 4-year old US children (95% uncertainty interval (UI), 13.7–14.2 million) were reached by the updated WIC nutrition standards from 2010 through 2019. In 2019, an estimated 62 700 (95% UI, 53 900–71 100) cases of childhood obesity were prevented, entirely among children from households with low incomes, leading to improved health equity. The update was estimated to cost $10 600 per quality-adjusted-life year gained (95% UI, $9760–$11 700). If WIC had reached all eligible children, more than twice as many cases of childhood obesity would have been prevented.

Conclusions

Updates to WIC’s nutrition standards for young children in 2009 were estimated to be highly cost-effective for preventing childhood obesity and contributed to reducing socioeconomic and racial/ethnic inequities in obesity prevalence. Improving nutrition policies for young children can be a sound public health investment; future research should explore how to improve access to them.

Funding

This study was supported by the National Institutes of Health (R01HL146625 and K01DK125278), The JPB Foundation, and the Centers for Disease Control and Prevention (U48DP006376). The authors have indicated they have no potential conflicts of interest to disclose. The findings and conclusions are those of the authors and do not necessarily represent the official position of the National Institutes of Health, the Centers for Disease Control and Prevention, or other funders.

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Cost-Effectiveness of Calorie Labeling at Large Fast-Food Chains Across the U.S.

Posted on January 15, 2024

This study evaluates the cost-effectiveness of calorie labeling at large U.S. fast-food chains.

Dupuis R, Block JP, Barrett JL, Long MW, Petimar J, Ward ZJ, Kenney EL, Musicus AA, Cannuscio CC, Williams DR, Bleich SN, Gortmaker SL. Cost Effectiveness of Calorie Labeling at Large Fast-Food Chains Across the U.S. Am J Prev Med. 2024 Jan;66(1):128-137. doi: 10.1016/j.amepre.2023.08.012. Epub 2023 Aug 14. PubMed PMID: 37586572; NIHMSID:NIHMS1929380.

Abstract

Introduction

Calorie labeling of standard menu items has been implemented at large restaurant chains across the United States since 2018. The objective of this study was to evaluate the cost-effectiveness of calorie labeling at large U.S. fast-food chains.

Methods

This study evaluated the national implementation of calorie labeling at large fast-food chains from a modified societal perspective and projected its cost-effectiveness over a ten-year period (2018-2027) using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model. Using evidence from over 67 million fast-food restaurant transactions between 2015 and 2019, the impact of calorie labeling on calorie consumption and obesity incidence was projected. Benefits were estimated across all racial, ethnic, and income groups. Analyses were performed in 2022.

Results

Calorie labeling is estimated to be cost-saving, prevent 550,000 cases of obesity in 2027 alone (95% uncertainty interval (UI): 518,000; 586,000), including 41,500 (95% UI: 33,700; 50,800) cases of childhood obesity, and save $22.60 in health care costs for every $1 spent by society in implementation costs. Calorie labeling is also projected to prevent cases of obesity across all racial and ethnic groups (range between 126-185 cases per 100,000 people) and all income groups (range between 152-186 cases per 100,000 people).

Conclusions

Calorie labeling at large fast-food chains is estimated to be a cost-saving intervention to improve long-term population health. Calorie labeling is a low-cost intervention that is already implemented across the U.S. in large chain restaurants.

Funding

Research reported in this publication was supported by the National Heart, Lung, and Blood Institute under Award Number R01HL146625, by the National Institute of Diabetes and Digestive and Kidney Diseases under Award Number R01DK115492, by the Centers for Disease Control and Prevention under Award Number U48DP006376, and by the JPB Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders. The funders had any role in study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication.

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A Sugar-Sweetened Beverage Excise Tax in California: Projected Benefits for Population Obesity and Health Equity

Posted on January 15, 2024

This study evaluates the cost-effectiveness of a hypothetical 2-cent-per-ounce excise tax in California (CA) and implications for population health and health equity.

Lee MM, Barrett JL, Kenney EL, Gouck J, Whetstone L, McCulloch SM, Cradock AL, Long MW, Ward ZJ, Rohrer B, Williams DR, Gortmaker SL. A Sugar-Sweetened Beverage Excise Tax in California: Projected Benefits for Population Obesity and Health Equity. Am J Prev Med. 2024 Jan;66(1):94-103. doi: 10.1016/j.amepre.2023.08.004. Epub 2023 Aug 6. PubMed PMID: 37553037;

Abstract

Introduction

Amid the successes of local sugar-sweetened beverage (SSB) taxes, interest in state-wide policies has grown. This study evaluated the cost-effectiveness of a hypothetical 2-cent-per-ounce excise tax in California (CA) and implications for population health and health equity.

Methods

Using the CHOICES microsimulation model, tax impacts on health, health equity, and cost-effectiveness over ten years in CA were projected, both overall and stratified by race/ethnicity and income. Expanding upon prior models, differences in the effect of SSB intake on weight by BMI category were incorporated. Costing was performed in 2020, and analyses were conducted in 2021-2022.

Results

The tax is projected to save $4.55b in healthcare costs, prevent 266,000 obesity cases in 2032, and gain 114,000 QALYs. Cost-effectiveness metrics, including the cost/QALY gained, were cost-saving. Spending on SSBs was projected to decrease by $33/adult and by $26/child in the first year overall. Reductions in obesity prevalence for Black and Hispanic Californians were 1.8 times larger compared to White Californians, and reductions for adults with lowest incomes (<130%FPL) were 1.4 times the reduction among those with highest incomes (>350%FPL). The tax is projected to save $112 in obesity-related healthcare costs per $1 invested.

Conclusions

A state-wide SSB tax in California would be cost saving and lead to reductions in obesity and improved SSB-related health equity, and lead to overall improvements in population health. The policy would generate more than $1.6 billion in state tax revenue annually that can also be used to improve health equity.

Funding

This work was supported by The JPB Foundation (Grant No. 1085), the National Institutes of Health (Grant No. R01HL146625), 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 or other agencies. The findings and conclusions in this article are those of the author(s) and do not necessarily represent the views or opinions of the California Department of Public Health or the California Health and Human Services Agency. The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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State-Specific Prevalence of Severe Obesity Among Adults in the United States Using Bias Correction of Self-Reported Body Mass Index

Posted on July 13, 2023

This study examines severe obesity prevalence among US adults by sociodemographic characteristics and by state after adjusting for self-report bias.

Zhao L, Park S, Ward ZJ, Cradock AL, Gortmaker SL, Blanck HM. State-Specific Prevalence of Severe Obesity Among Adults in the US Using Bias Correction of Self-Reported Body Mass Index. Prev Chronic Dis. 2023 Jul;20. doi:10.5888/pcd20.230005

Abstract

Introduction

Adults with severe obesity are at increased risk for poor metabolic health and may need more intensive clinical and community supports. The prevalence of severe obesity is underestimated from self-reported weight and height data. We examined severe obesity prevalence among US adults by sociodemographic characteristics and by state after adjusting for self-report bias.

Methods

Using a validated bias-correction method, we adjusted self-reported body mass index (BMI) data from the 2020 Behavioral Risk Factor Surveillance System (BRFSS) by using measured data from the National Health and Nutrition Examination Survey. We compared bias-corrected prevalence of severe obesity (BMI ≥40) with self-reported estimates by sociodemographic characteristics and state.

Results

Self-reported BRFSS data significantly underestimated the prevalence of severe obesity compared with bias-corrected estimates. In 2020, 8.8% of adults had severe obesity based on the bias-corrected estimates, whereas 5.3% of adults had severe obesity based on self-reported data. Women had a significantly higher prevalence of bias-corrected severe obesity (11.1%) than men (6.5%). State-level prevalence of bias-corrected severe obesity ranged from 5.5% (Massachusetts) to 13.2% (West Virginia). Based on bias-corrected estimates, 16 states had a prevalence of severe obesity greater than 10%, a level not seen in the self-reported estimates.

Conclusion

Self-reported BRFSS data underestimated the overall prevalence of severe obesity by 40% (5.3% vs 8.8%). Accurate state-level estimates of severe obesity can help public health and health care decision makers prioritize and plan to implement effective prevention and treatment strategies for people who are at high risk for poor metabolic health.

Funding

The work of Drs Ward, Cradock, and Gortmaker was supported in part by grants from The JPB Foundation, the National Institutes of Health (R01HL146625), and CDC (U48DP006376). The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of CDC or other funders. No copyrighted materials were used in this research.

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