Resource Type: Peer-Reviewed Publications

Cost-Effectiveness of a Clinical Childhood Obesity Intervention

Posted on November 1, 2017

A CHOICES study estimates that the national implementation of an intervention focused on electronic health record (EHR)-based decision support for primary care providers and self-guided behavior change support for parents is likely a more cost-effective approach to treating children with obesity than previous clinical interventions reporting cost information.

Sharifi M, Franz C, Horan CM, Giles C, Long M, Ward Z, Resch S, Marshall R, Gortmaker S, Taveras E. Cost-Effectiveness of a Clinical Childhood Obesity Intervention. Pediatrics. 2017; 140(5):e20162998.

Over 12 million children and adolescents in the United States have obesity (17% of the population). The results of this study demonstrate that taking advantage of electronic health record (EHR) systems may be among the “best value for money” strategies currently tested for pediatric obesity treatment.

“It is clear that the most cost-effective strategies for preventing new cases of obesity are population-level approaches like taxes and school-based policies,” said Mona Sharifi, lead author and Assistant Professor of Pediatrics at the Yale School of Medicine. “However, we need additional and different strategies to support the approximately 12 million children who already have obesity and are at highest risk for health complications and obesity in adulthood. Our study suggests that using the electronic health record to help primary care pediatricians deliver higher quality care for children with obesity may be relatively low hanging fruit among clinical interventions in terms of cost-effectiveness.”

The Study of Technology to Accelerate Research (STAR)¹ involved modifications to existing EHR systems to facilitate childhood obesity management in pediatric primary care by prompting diagnosis as well as providing decision support and electronic resources for evaluation, management, and follow-up care. Evidence obtained in a cluster randomized controlled trial showed that STAR helped to prevent excess weight gain compared to usual care.

The CHOICES study of STAR offers an opportunity to both inform clinicians and policymakers about what investment would be required to adopt STAR in pediatric practices across the country and evaluate the cost-effectiveness and population impact of the intervention, if implemented nationally over 10 years from 2015-2025. Some of the key outcomes include:

Cases of obesity averted in 2025: 43,000
Life-years with obesity averted (2015-2025): 226,000
Cost per BMI unit reduced: $237
Mean BMI unit reduction: -0.5
10-year reach: 2 million
Total health care costs saved (over 10 years): $64 million
10-year net cost (the cost of implementation minus the health care cost saved): $175 million
Cost per child: $119

As more pediatric practices adopt fully functional EHRs (fueled by federal goals and incentives), the results indicate even greater reach and population health benefits, even if implementation is limited to large practices.

Overall, there is evidence that STAR can reduce the prevalence of childhood obesity by focusing on high-risk children, providing electronic decision support for pediatricians, and supplying self-guided behavior change strategies for parents to utilize outside of the clinical setting. Limited cost effectiveness information on other similar clinical interventions indicates that STAR is likely to have a higher magnitude of effect on improving children’s health at a lower cost per child.

STAR is one of 13 interventions that have been evaluated using CHOICES methods. While many strategies focused on preventing childhood obesity are more cost-effective than STAR, the projected impact of the STAR intervention on the prevalence of obesity is high and intervention costs are low when compared with other clinical interventions focused on treatment of obesity, such as bariatric surgery.

References:

Taveras EM, Marshall R, Kleinman KP, et al. Comparative effectiveness of childhood obesity interventions in pediatric primary care: A cluster-randomized clinical trial. (link: https://www.ncbi.nlm.nih.gov/pubmed/25895016) JAMA Pediatr. 2015;169(6):535-542.

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Using Cost-Effectiveness Analysis to Prioritize Policy and Programmatic Approaches to Physical Activity Promotion and Obesity Prevention in Childhood

Posted on February 28, 2017

A CHOICES study found that six interventions in school, afterschool, and childcare settings in the U.S. could increase physical activity among children and adolescents and also prevent cases of childhood obesity.

Cradock AL, Barrett JL, Kenney EL, Giles CM, Ward ZJ, Long MW, Resch SC, Pipito AA, Wei ER, Gortmaker SL. Using cost-effectiveness analysis to prioritize policy and programmatic approaches to physical activity promotion and obesity prevention in childhood. Prev Med. 2017 Feb;95 Suppl:S17-S27. doi: 10.1016/j.ypmed.2016.10.017

Though national guidelines from the U.S. Department of Health and Human Services (2008) recommend that both children and adolescents participate in 60 minutes or more of moderate to vigorous physical activity (MVPA) per day, many in this age group throughout the U.S. do not meet this standard. A variety of interventions can increase physical activity among youth, but implementation can be challenging for decision makers who have limited resources and implementation guidance.

The Childhood Obesity Intervention Cost Effectiveness Study (CHOICES) study team identified six physical activity interventions via a systematic review process to project the ten-year population reach, health impact, implementation cost, and health care cost savings of national implementation of each strategy. The six interventions analyzed for cost-effectiveness included:

Active Physical Education (Active PE): Focuses on making the time that children spend in PE class more active
Active Recess: Focuses on making the time that children spend in school recess periods more active
Active School Day: Centers on the integration of strategies to increase physical activity during the school day via Active PE, Active Recess, and movement breaks within the classroom
Healthy Afterschool: Focuses on improving physical activity, nutrition, and screen time practices and policies in existing afterschool programs
New Afterschool Programs: Centers on creating afterschool programs that include time for physical activity and nutritious snacks for children who otherwise would not attend afterschool programs
Hip Hop to Health, Jr.: Focuses on providing structured physical activity in early childcare settings

For all six physical activity-increasing interventions, both cost-effectiveness and obesity impact were modeled. When compared to a base case of no intervention, all six interventions in school, afterschool, and childcare settings are expected to result in significant health care cost savings and reduced cases of childhood obesity in 2025. The main highlights of the study included that:

All interventions would increase youth physical activity levels (0.05 to 1.29 MET-hour/day).
The cost per MET-hour change/day ranged from cost-saving to $3.14.
The interventions could prevent between 2500 and 110,000 cases of children with obesity.

The analysis of these six interventions can provide valuable information to decision-makers on different strategies within structured settings where children spend a lot of time to guide them to the best value for their investment. It can also serve as an impetus for prioritizing the need for improved physical activity interventions and childhood obesity prevention strategies in school, afterschool, and childcare settings.

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State-Level Estimates of Childhood Obesity Prevalence in the United States Corrected for Report Bias

Posted on August 31, 2016

Long MW, Ward ZJ, Resch SC, Cradock AL, Wang YC, Giles CM, Gortmaker SL. State-level estimates of childhood obesity prevalence in the United States corrected for report bias. Int J Obes (Lond). Epub 2016 Jul 27.

Abstract

Background/objectives

State-specific obesity prevalence data are critical to public health efforts to address the childhood obesity epidemic. However, few states administer objectively measured body mass index (BMI) surveillance programs. This study reports state-specific childhood obesity prevalence by age and sex correcting for parent-reported child height and weight bias.

Subjects/methods

As part of the Childhood Obesity Intervention Cost Effectiveness Study (CHOICES), we developed childhood obesity prevalence estimates for states for the period 2005-2010 using data from the 2010 US Census and American Community Survey (ACS), 2003-2004 and 2007-2008 National Survey of Children’s Health (NSCH) (n=133 213), and 2005-2010 National Health and Nutrition Examination Surveys (NHANES) (n=9377; ages 2-17). Measured height and weight data from NHANES were used to correct parent-report bias in NSCH using a non-parametric statistical matching algorithm. Model estimates were validated against surveillance data from five states (AR, FL, MA, PA and TN) that conduct censuses of children across a range of grades.

Results

Parent-reported height and weight resulted in the largest overestimation of childhood obesity in males ages 2-5 years (NSCH: 42.36% vs NHANES: 11.44%). The CHOICES model estimates for this group (12.81%) and for all age and sex categories were not statistically different from NHANES. Our modeled obesity prevalence aligned closely with measured data from five validation states, with a 0.64 percentage point mean difference (range: 0.23-1.39) and a high correlation coefficient (r=0.96, P=0.009). Estimated state-specific childhood obesity prevalence ranged from 11.0 to 20.4%.

Conclusion

Uncorrected estimates of childhood obesity prevalence from NSCH vary widely from measured national data, from a 278% overestimate among males aged 2-5 years to a 44% underestimate among females aged 14-17 years. This study demonstrates the validity of the CHOICES matching methods to correct the bias of parent-reported BMI data and highlights the need for public release of more recent data from the 2011 to 2012 NSCH.

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U.S. States’ Childhood Obesity Surveillance Practices and Recommendations for Improving Them, 2014–2015

Posted on July 29, 2016

Blondin KJ, Giles CM, Cradock AL, Gortmaker SL, Long MW. US States’ Childhood Obesity Surveillance Practices and Recommendations for Improving Them, 2014–2015. Prev Chronic Dis. 2016;13:160060.

Abstract

Introduction

Routine collection, analysis, and reporting of data on child height, weight, and body mass index (BMI), particularly at the state and local levels, are needed to monitor the childhood obesity epidemic, plan intervention strategies, and evaluate the impact of interventions. Child BMI surveillance systems operated by the US government do not provide state or local data on children across a range of ages. The objective of this study was to describe the extent to which state governments conduct child BMI surveillance.

Methods

From August through December 2014, we conducted a structured telephone survey with state government administrators to learn about state surveillance of child BMI. We also searched websites of state health and education agencies for information about state surveillance.

Results

State agency administrators in 48 states and Washington, DC, completed telephone interviews (96% response rate). Based on our interviews and Internet research, we determined that 14 states collect child BMI data in a manner consistent with standard definitions of public health surveillance.

Conclusion

The absence of child BMI surveillance systems in most states limits the ability of public health practitioners and policymakers to develop and evaluate responses to the childhood obesity epidemic. Greater investment in surveillance is needed to identify the most effective and cost-effective childhood obesity interventions.

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New Strategies to Prioritize Nutrition, Physical Activity, and Obesity Interventions

Posted on April 27, 2016

Dietz WH, Gortmaker SL. New Strategies to Prioritize Nutrition, Physical Activity, and Obesity Interventions. Am J Prev Med. 2016 Apr 26. pii: S0749-3797(16)30069-1.

Abstract

Interventions for obesity have not often been based on considerations that could predict their effectiveness. However, advances in research provide several new approaches that can inform priorities for public health interventions directed at nutrition, physical activity, and obesity. These approaches include estimation of the effect size, comparison of the calorie gap with the caloric deficit induced by the intervention, population reach and impact, cost and cost effectiveness of the intervention, time required to evaluate the effect of the intervention on weight change, and feasibility of the intervention. Incorporation of these considerations by policymakers and public health practitioners will help identify those interventions most likely to achieve changes in the prevalence of obesity.

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Redrawing the US Obesity Landscape: Bias-Corrected Estimates of State-Specific Adult Obesity Prevalence

Posted on March 9, 2016

A CHOICES paper reveals that adult obesity rates in the United States are higher than previously reported by the CDC.

Ward ZJ, Long MW, Resch SC, Gortmaker SL, Cradock AL, Giles C, Hsiao A, Wang YC. Redrawing the US Obesity Landscape: Bias-Corrected Estimates of State-Specific Adult Obesity Prevalence. PLoS ONE. 2016 Mar 8;11(3):e0150735.

[Fig 1.] Prevalence of adult obesity (BMI ≥ 30) by state in 2013: Uncorrected vs. Corrected.

Adult overweight and obesity are among the leading causes of morbidity and mortality in the United States—a problem depicted in the Centers for Disease Control and Prevention’s (CDC) well-known obesity maps. However these figures—which have galvanized state leaders to take action, and have been used to prioritize federal obesity prevention resources—may substantially underestimate the true state-level burden. The data behind these maps rely on self-reported height and weight collected through telephone surveys, yet bias in self-reported measures is well documented and results in underestimates of body mass index (BMI). The CHOICES Project, which created a novel method to correct for this bias, found that as many as 12 million adults with obesity (including 6.7 million with severe obesity) were misclassified by CDC state-level estimates.

“Accurate estimates of state-level obesity are necessary to plan for resources to address this epidemic,” said Zachary Ward, lead author and programmer/analyst in the Center for Health Decision Science at the Harvard T.H. Chan School of Public Health. “Our corrected state-level estimates provide decision makers with a more solid foundation of data on which to base obesity prevention policies.”

[Fig 2.] Prevalence of adult severe obesity (BMI ≥ 35) by state in 2013: Uncorrected vs. Corrected.

A closer look at specific states reveals some striking findings. In the adjusted data [Fig. 1], obesity prevalence was below 30 percent in only four states (California, Colorado, Hawaii, and Massachusetts), whereas the CDC maps show most states below this level. Another key finding is that in four states (Arkansas, Mississippi, Tennessee, and West Virginia), the estimated obesity prevalence was over 40 percent—a category not included in any previous CDC data. Also not seen in the existing maps is the prevalence of severe obesity greater than 17.5 percent, now apparent in Alabama, Mississippi, and West Virginia [Fig. 2].

Further, the economic implications of under-counting millions of cases of obesity are large. Assuming incremental obesity-related healthcare costs of $1,000 per individual, under-counting the total 12 million cases of obesity would result in underestimating obesity-related healthcare costs by $12 billion.

These revised maps highlight the need for improved resources to both track and prevent obesity. It is important to note that the Behavioral Risk Factor Surveillance System, on which the CDC maps are based, is the only national BMI surveillance strategy currently in place for gathering state-specific information. These data are crucial, and are what allowed for the adjustments used in this study. Accurate state-specific obesity estimates are necessary to help officials plan appropriately for the medical capacity and economic resources needed to address this epidemic, and institute preventive measures where they are needed most.

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Three Interventions That Reduce Childhood Obesity Are Projected to Save More Than They Cost to Implement

Posted on December 1, 2015

A CHOICES paper identifying cost-effective nutrition interventions with broad population reach highlights the importance of primary prevention for policy makers aiming to reduce childhood obesity.

Gortmaker SL, Claire Wang Y, Long MW, Giles CM, Ward ZJ, Barrett JL, Kenney EL, Sonneville KR, Afzal AS, Resch SC, Cradock AL. Three Interventions That Reduce Childhood Obesity Are Projected to Save More Than They Cost to Implement. Health Aff, 34, no. 11 (2015):1304-1311.

Graph of impact of interventions outlined in article

Reused with permission from Project HOPE/Health Affairs. The published article is archived and available online at www.healthaffairs.org.

The United States will not be able to treat its way out of the obesity epidemic with current clinical practice. Instead, reversing the tide of obesity will require expanded investment in primary prevention, focusing on a combination of interventions with broad population reach, proven individual effectiveness, and low cost of implementation.

This study is the first of its kind to estimate the cost effectiveness of a wide variety of nutrition interventions high on the obesity policy agenda—documenting their potential reach, comparative effectiveness, implementation cost, and cost-effectiveness. Researchers identified three interventions that would more than pay for themselves by reducing healthcare costs related to obesity: an excise tax on sugar-sweetened beverages; elimination of the tax subsidy for advertising unhealthy food to children; and nutrition standards for food and drinks sold in schools outside of school meals. Implemented nationally, these interventions would prevent 576,000, 129,100, and 345,000 cases of childhood obesity, respectively, in 2025. The projected net savings to society in obesity-related health care costs for each dollar spent would be $30.78, $32.53, and $4.56, respectively.

Additional interventions modeled include restaurant menu calorie labeling, increased access to adolescent bariatric surgery, improved early care and education, and nutrition standards for school meals. The study points out that the improvements in nutrition standards for both school meals and foods and beverages sold outside of meals through current Smart Snacks in School regulation make the Healthy, Hunger-Free Kids Act of 2010 one of the most important national obesity prevention policy achievements in recent decades.

Though researchers analyzed interventions separately, no strategy on its own would be sufficient to reverse the obesity epidemic. The study also emphasizes the importance of obesity prevention that spans across multiple settings throughout the life course. While childhood interventions are necessary to reduce obesity during the early years of life and ensure that children enter into adulthood at a healthy weight, it is critical that environments spanning the life course continue to support healthy eating and drinking behaviors.

“Policy makers looking to reverse the childhood obesity epidemic and reduce long-term obesity prevalence need to focus on implementing cost-effective preventive interventions that reach a large percentage of our nation’s children,” says lead investigator of the CHOICES Project, Dr. Steve Gortmaker, who also serves as a Professor of the Practice of Health Sociology and the Director of the Prevention Research Center on Nutrition and Physical Activity at the Harvard T.H. Chan School of Public Health.

The study notes that interventions affecting both children and adults are particularly attractive, since near-term health care cost savings can be achieved by reducing adult obesity, while laying the ground work for long-term cost savings by reducing childhood obesity. The sugar-sweetened beverage excise tax, for example, would save $14.2 billion in net costs over the course of the decade, primarily due to reductions in adult health care costs.

Interventions that can achieve near-term health cost savings among adults and reduce childhood obesity offer policy makers an opportunity to make long-term investments in children’s health while generating short-term returns.

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Severe Obesity In Adults Cost State Medicaid Programs Nearly $8 Billion In 2013

Posted on November 30, 2015

Wang YC, Pamplin J, Long MW, Ward ZJ, Gortmaker SL, Andreyeva T. Severe Obesity In Adults Cost State Medicaid Programs Nearly $8 Billion In 2013. Health Aff, 34, no. 11 (2015):1923-31.

Abstract

Efforts to expand Medicaid while controlling spending must be informed by a deeper understanding of the extent to which the high medical costs associated with severe obesity (having a body mass index of [Formula: see text] or higher) determine spending at the state level. Our analysis of population-representative data indicates that in 2013, severe obesity cost the nation approximately $69 billion, which accounted for 60 percent of total obesity-related costs. Approximately 11 percent of the cost of severe obesity was paid for by Medicaid, 30 percent by Medicare and other federal health programs, 27 percent by private health plans, and 30 percent out of pocket. Overall, severe obesity cost state Medicaid programs almost $8 billion a year, ranging from $5 million in Wyoming to $1.3 billion in California. These costs are likely to increase following Medicaid expansion and enhanced coverage of weight loss therapies in the form of nutrition consultation, drug therapy, and bariatric surgery. Ensuring and expanding Medicaid-eligible populations’ access to cost-effective treatment for severe obesity should be part of each state’s strategy to mitigate rising obesity-related health care costs.

Keywords: Epidemiology; Health Promotion/Disease Prevention; Medicaid; Public Health.

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Cost-Effectiveness of Childhood Obesity Interventions: Evidence and Methods for CHOICES

Posted on July 31, 2015

A published CHOICES overview paper discusses the rigorous methods behind four preventive childhood obesity strategies that were found to be more cost-effective than existing clinical interventions to treat obesity.

Gortmaker SL, Long MW, Resch SC, Ward ZJ, Cradock AL, Barrett JL, Wright DR, Sonneville KR, Giles CM, Carter RC, Moodie ML, Sacks G, Swinburn BA, Hsiao A, Vine S, Barendregt J, Vos T, Wang YC. Cost Effectiveness of Childhood Obesity Interventions: Evidence and Methods for CHOICES. Am J Prev Med. 2015 Jul;49(1):102-11. doi: 10.1016/j.amepre.2015.03.032.

As the childhood obesity epidemic continues in the U.S., fiscal crises are leading policymakers to ask not only whether an intervention works, but also whether it offers good value for money spent. However, cost-effectiveness analyses have been limited, and currently practiced strategies such as individual clinical interventions are often an expensive burden on the healthcare system.

“Reversing the obesity epidemic will require a broad range of intervention strategies, and identifying the best strategies necessitates analysis of the costs, impact, healthcare cost savings, and broader context of each strategy,” says lead investigator of the CHOICES Project, Dr. Steve Gortmaker, who also serves as the Director of the Harvard Prevention Research Center and a Professor of the Practice of Health Sociology at the Harvard T.H. Chan School of Public Health. “The consideration of all these key metrics is crucial, yet currently absent from our national conversation on obesity prevention and control.”

The four papers, published by the American Journal of Preventive Medicine, are the first to evaluate the cost-effectiveness of these four strategies implemented nationally:

a sugar-sweetened beverage (SSB) excise tax
eliminating the tax subsidy of TV advertising unhealthy food to children (TV AD)
early care and education policy changes targeting unhealthy beverages, physical activity, and screen time (ECE)
policy changes and teacher training to increase physical activity during existing PE classes (ACTIVE PE)

CHOICES researchers selected these initial interventions as they represent a broad range of nationally scalable strategies to reduce childhood obesity, using a mix of both policy and program-based changes. The interventions were modeled for nationwide implementation using a simulation of the 2015 U.S. population over ten years. Population reach varied widely, and cost per BMI change ranged from $1.16 (TV AD) to $401 (Active PE). At the 10-year mark in 2025, three interventions would save net costs, with SSB and TV AD saving $55 and $38 for every dollar spent. The SSB intervention would avert disability-adjusted life years, and both SSB and TV AD would increase quality-adjusted life years. Both SSB ($12.5 billion) and TV AD ($80 million) would produce yearly tax revenue.

The overview also discusses various limitations in current research and results, including the lack of established benchmarks for the metric of cost per unit changes in BMI. However for comparison, the paper cites the costs of existing clinical interventions for obese children or adolescents. When primary care-based interventions can total about $1,000 per BMI unit change, and bariatric surgery is roughly estimated at $2,100 per BMI unit change, the results from the four CHOICES broad-reaching policy and preventive interventions may produce changes in BMI at much lower cost than these commonly reimbursed medical treatments.

Though the critical question remains of whether these cost-effective interventions can actually be implemented over the modeled length of time (and whether implementation is at the local, state, or national level), this analysis is an important step in providing policymakers with the right tools to focus on strategies that can demonstrate best value for money.

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Cost-Effectiveness of a Sugar-Sweetened Beverage Excise Tax in the U.S.

Posted on July 31, 2015

Implementing a national sugar-sweetened beverage excise tax could substantially reduce body mass index (BMI) and health care expenditures over 10 years, and increase healthy life expectancy in the US.

Long MW, Gortmaker SL, Ward ZJ, Resch SC, Moodie ML, Sacks G, Swinburn BA, Carter RC, Claire Wang Y. Cost Effectiveness of a Sugar-Sweetened Beverage Excise Tax in the U.S. Am J Prev Med. 2015 Jul;49(1):112-23. doi: 10.1016/j.amepre.2015.03.004.

The close link between consumption of sugar-sweetened beverages (SSB) and excess weight gain, diabetes, and cardiovascular disease has led to public health recommendations for higher taxes on unhealthy drinks like soda and sports drinks. While a number of studies have found that higher beverage taxes and prices are associated with significantly lower BMI, this is the first study to estimate the cost effectiveness of implementing a $0.01 per ounce SSB excise tax in the US.

By using a simulation model, the study found that implementing the tax nationally would cost $51 million in the first year and would reduce SSB consumption by 20%, substantially reducing BMI among both youth and adults. Over a 10-year period, the tax would avert 101,000 disability-adjusted life years, gain 871,000 quality-adjusted life years, and result in $23.6 billion in healthcare cost savings. Annually, the tax would generate revenue totaling $12.5 billion.

“We know that the current level of sugar-sweetened beverage consumption in the United States is doing real harm to our children, our families, and our society by increasing the risk of obesity, diabetes, and cardiovascular disease, leading to increased healthcare costs and early deaths,” says lead study author Michael Long, ScD, a postdoctoral research fellow at the Harvard Prevention Research Center. “The question is: what are we going to do about it? Our study shows that a small tax on the production of these beverages can prevent obesity, save lives, and reduce healthcare costs for the country. This is a low-cost prevention strategy that could also raise revenue to fund community programs to promote healthy eating and physical activity.”

In contrast to sales taxes that are collected from the consumer at time of purchase, this per-volume excise tax would apply to producers and distributors of sugar-sweetened beverages and would be incorporated into shelf prices, leading to an estimated 16% total price increase for sodas, sports drinks, fruit drinks, and any other beverages with added caloric sweeteners.

Implementing an excise tax on sugar-sweetened beverages could serve as a powerful social signal to reduce sugar consumption through additional individual behavioral and policy changes. In the ongoing debate over policy approaches to curb the obesity epidemic in the US, this analysis provides important new information to policymakers and the public regarding the substantial savings in both human health and government expenditures that could be achieved.

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