Resource Type: Peer-Reviewed Publications

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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BMI and Healthcare Cost Impact of Eliminating Tax Subsidy for Advertising Unhealthy Food to Youth

Posted on July 31, 2015

CHOICES research found that eliminating the tax subsidy of TV advertising costs for unhealthy food and beverages advertised to children and adolescents could be a cost-saving strategy to reduce childhood obesity and related healthcare expenditures.

Sonneville KR, Long MW, Ward ZJ, Resch SC, Wang YC, Pomeranz JL, Moodie ML, Carter R, Sacks G, Swinburn BA, Gortmaker SL. BMI and Healthcare Cost Impact of Eliminating Tax Subsidy for Advertising Unhealthy Food to Youth. Am J Prev Med. 2015 Jul;49(1):124-34. doi: 10.1016/j.amepre.2015.02.026.

Every year, children in the US are exposed to thousands of food-related TV advertisements, most of which promote nutritionally poor foods and drinks. Despite changes in media consumption, TV remains the predominant platform to reach youth, and the advertising industry knows it. Food marketers spend millions of dollars on youth-directed television each year, and these advertising expenditures are currently treated by the US government as an ordinary business expense. In 2009, for example, the food and beverage industry received a tax subsidy of nearly $80 million for the $633 million spent on TV advertising to children.

With factors such as the US Constitution’s protection of marketing as commercial speech and the government’s reluctance to regulate even minimal restrictions on advertising, eliminating or amending the tax deduction available to food companies for the costs of advertising to children has been proposed.

“By changing the tax treatment of advertising expenses, the food industry will have less incentive to advertise unhealthy foods and drinks to kids,” says lead author Kendrin Sonneville, ScD, RD, Director of Nutrition Training in the Division of Adolescent Medicine at Boston Children’s Hospital.

The study intervention involved the elimination of this tax subsidy, applying to television programming watched on traditional TV and to television advertising aired during children’s programming, reaching nearly 74 million youth between the ages of two to 19. By using a simulation model, the researchers estimated that the intervention would reduce an aggregate 2.13 million BMI units in the population, costing $1.16 per BMI unit reduced. Over a 10-year period, the intervention would result in $352 million in healthcare cost savings and gain 4,538 quality-adjusted life years (QALYs).

While the effects of the intervention may be small at the individual level, such a policy could have substantial impact on healthcare expenditure at the population level. Although the policy would likely be met with opposition from the food industry, eliminating the tax subsidy of advertising expenses would also generate tax revenue and is likely to receive strong public support. The study provides important information for a feasible approach to reducing children’s advertising exposure.

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Modeling the Cost-Effectiveness of Child Care Policy Changes in the U.S.

Posted on July 31, 2015

CHOICES researchers found that implementing a multi-component regulatory policy in US childcare facilities would lead children to watch less TV, get more physical activity, and consume fewer sugary drinks, serving as a cost-effective strategy in reducing the childhood obesity epidemic.

Wright DR, Kenney EL, Giles CM, Long MW, Ward ZJ, Resch SC, Moodie ML, Carter RC, Wang YC, Sacks G, Swinburn BA, Gortmaker SL, Cradock AL. Modeling the Cost Effectiveness of Child Care Policy Changes in the U.S. Am J Prev Med. 2015 Jul;49(1):135-47. doi: 10.1016/j.amepre.2015.03.016.

Risk factors for obesity, including dietary habits, physical activity, and screen time behaviors develop in early childhood, persisting into late childhood and even into adulthood. Long-term habits are hard to change during adulthood, highlighting the importance of early intervention for obesity prevention. With nearly 70 percent of American preschool-aged children in out-of-home child care facilities, the setting serves as an ideal intervention target.

“Full day childcare programs are an educational environment responsible for providing children with snacks, meals, and daily opportunities for physical activity,” says lead author, Davene Wright, PhD, an Assistant Professor in the Department of Pediatrics at the University of Washington School of Medicine. “Many childcare programs fail to meet best practice standards for nutrition, physical activity, and screen time viewing. When 20 percent of preschool-aged children in the US are currently overweight or obese, this sector should be a key target for policy regulations to aid in the development of lifelong healthy behaviors.”

The study developed a hypothetical state-level regulatory policy intervention with three components:

The beverage component stipulated that water be made freely available throughout the program day, that sugar-sweetened beverages (SSBs) be replaced with water, that 100% juice be limited to 6 ounces per child per day, and that whole milk be replaced with reduced-fat milk.
The physical activity component required programs to provide opportunities for at least 90 minutes of moderate and vigorous physical activity (MVPA) over the course of the program day for children in full-time care.
The screen time component specified that television and computer time be educational in nature and limited to 30 minutes per week.

By using a simulation model, researchers found that these regulatory changes would reach 3.8 million US preschool-aged children, resulting in 21 hours of less screen time, 5 hours more of MVPA, 588 fewer ounces of whole milk, and 40 fewer ounces of SSBs annually per child. Implementation would cost $7.4 million annually, and result in 0.02 fewer BMI units per child at a cost of $58 per BMI unit avoided. Over a 10-year period, these effects would result in net healthcare cost savings of $372 million.

This is the first study to examine the potential economic impact of a multi-component child care-based obesity policy intervention. These regulations could have a small but meaningful impact on short-term BMI at a low cost, with promising potential to be cost-saving within only 10 years. This analysis provides important new information to policymakers regarding the benefits to the health of our nation’s children, and the substantial savings to healthcare expenditures that could be achieved.

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Cost-Effectiveness of an Elementary School Active Physical Education Policy

Posted on July 31, 2015

A diverse group of children playing basketball.

A CHOICES study found that implementing an active physical education policy at the elementary school level increases physical activity and could lead to future reductions in BMI and obesity-related healthcare expenditures.

Barrett JL, Gortmaker SL, Long MW, Ward ZJ, Resch SC, Moodie ML, Carter R, Sacks G, Swinburn BA, Wang YC, Cradock AL. Cost Effectiveness of an Elementary School Active Physical Education Policy. Am J Prev Med. 2015 Jul;49(1):148-59. doi: 10.1016/j.amepre.2015.02.005.

Upon visiting an elementary school physical education (PE) class, you would expect to find children engaged in exercise. In reality, the typical PE class in the US may not be so active. While most elementary schools do require some PE, students on average spend less than half of class time engaged in moderate-to-vigorous physical activity (MVPA). Additionally, PE activity levels are lower when more class time is spent organizing students or reviewing rules and techniques, and when PE classes are led by classroom teachers instead of trained PE specialists.

In recent years, school districts and states have pursued “active PE” policies, or policies aimed at increasing MVPA levels during PE class. In this study, researchers modeled an active PE policy intervention based on those passed by state legislatures in Texas and Oklahoma. The intervention policy specified the requirement that “50 percent of PE time be devoted to MVPA,” and implementation was assumed to take place during existing PE classes.

Using a simulation model, researchers scaled the state-based active PE policy to a national level and found that it would increase MVPA per 30-minute PE class by nearly two minutes, and cost $70 million in the first year to implement. BMI could be reduced after two years, and the policy would reduce healthcare costs by $60 million over a 10-year period.

“Physical education is the building block for getting kids active during the school day,” says lead author Jessica Barrett, MPH, a data manager and analyst and the Harvard Prevention Research Center. “We found that a policy ensuring that kids are active during PE class can increase physical activity levels and reduce healthcare costs. Even small increases in physical activity can lead to better health and also better learning for students in the classroom.”

The intervention was estimated to reach more than 17 million children aged 6–11 years attending over 47,000 public elementary schools in the 47 states eligible to adopt the active PE policy, representing 71% of the total 2015 US population in that age group. The study demonstrates the positive impact of an active PE policy, at a cost that appears reasonable compared to alternative approaches for increasing physical activity among children.

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Systematic Review and Meta-Analysis of the Impact of Restaurant Menu Calorie Labeling

Posted on June 24, 2015

Menu calorie labeling identified as a relatively low-cost education strategy that may lead consumers to purchase slightly fewer calories.

Long MW, Tobias DK, Cradock AL, Batchelder H, Gortmaker SL. Systematic Review and Meta-analysis of the Impact of Restaurant Menu Calorie Labeling. Am J Public Health. 2015 May;105(5):e11-24. doi: 10.2105/AJPH.2015.302570. Epub 2015 Mar 19.

A number of studies have examined the relationship between menu calorie labeling and the calories consumers ordered or purchased in a variety of settings with differing results. To get a combined effect estimate for modeling the cost effectiveness of the federal menu labeling policy, CHOICES researcher Dr. Michael Long conducted a systematic review and meta-analysis. While the meta-analysis evidence does not support a significant impact on calories ordered, menu calorie labeling is a relatively low-cost education strategy that may lead consumers to purchase slightly fewer calories.

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