Resource Type: Peer-Reviewed Publications

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

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.

Children crowded around an iPad“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. 

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.

Children playing in daycare“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

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.

Children playing basketballUpon 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

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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The Cost of a Primary Case-Based Childhood Obesity Prevention Intervention

Wright DR, Taveras EM, Gillman MW, Horan CM, Hohman KH, Gortmaker SL, Prosser LA. The cost of a primary care-based childhood obesity prevention intervention. BMC Health Serv Res. 2014 Jan 29;14:44. doi: 10.1186/1472-6963-14-44.

Abstract

Background

United States pediatric guidelines recommend that childhood obesity counseling be conducted in the primary care setting. Primary care-based interventions can be effective in improving health behaviors, but also costly. The purpose of this study was to evaluate the cost of a primary care-based obesity prevention intervention targeting children between the ages of two and six years who are at elevated risk for obesity, measured against usual care.

Methods

High Five for Kids was a cluster-randomized controlled clinical trial that aimed to modify children’s nutrition and TV viewing habits through a motivational interviewing intervention. We assessed visit-related costs from a societal perspective, including provider-incurred direct medical costs, provider-incurred equipment costs, parent time costs and parent out-of-pocket costs, in 2011 dollars for the intervention (n = 253) and usual care (n =192) groups. We conducted a net cost analysis using both societal and health plan costing perspectives and conducted one-way sensitivity and uncertainty analyses on results.

Results

The total costs for the intervention group and usual care groups in the first year of the intervention were $65,643 (95% CI [$64,522, $66,842]) and $12,192 (95% CI [$11,393, $13,174]). The mean costs for the intervention and usual care groups were $259 (95% CI [$255, $264]) and $63 (95% CI [$59, $69]) per child, respectively, for a incremental difference of $196 (95% CI [$191, $202]) per child. Children in the intervention group attended a mean of 2.4 of a possible 4 in-person visits and received 0.45 of a possible 2 counseling phone calls. Provider-incurred costs were the primary driver of cost estimates in sensitivity analyses.

Conclusions

High Five for Kids was a resource-intensive intervention. Further studies are needed to assess the cost-effectiveness of the intervention relative to other pediatric obesity interventions.

Trial registration: ClinicalTrials.gov NCT00377767.

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Reaching the Healthy People Goals for Reducing Childhood Obesity: Closing the Energy Gap

Wang YC, Orleans CT, Gortmaker SL. Reaching the healthy people goals for reducing childhood obesity: Closing the energy gap. Am J Prev Med. 2012 May;42(5):437-44. doi: 10.1016/j.amepre.2012.01.018.

Abstract

Background

The federal government has set measurable goals for reducing childhood obesity to 5% by 2010 (Healthy People 2010), and 10% lower than 2005-2008 levels by 2020 (Healthy People 2020). However, population-level estimates of the changes in daily energy balance needed to reach these goals are lacking.

Purpose

To estimate needed per capita reductions in youths’ daily “energy gap” (calories consumed over calories expended) to achieve Healthy People goals by 2020.

Methods

Analyses were conducted in 2010 to fit multivariate models using National Health and Nutrition Examination Surveys 1971-2008 (N=46,164) to extrapolate past trends in obesity prevalence, weight, and BMI among youth aged 2-19 years. Differences in average daily energy requirements between the extrapolated 2020 levels and Healthy People scenarios were estimated.

Results

During 1971-2008, mean BMI and weight among U.S. youth increased by 0.55 kg/m(2) and by 1.54 kg per decade, respectively. Extrapolating from these trends to 2020, the average weight among youth in 2020 would increase by ∼1.8 kg from 2007-2008 levels. Averting this increase will require an average reduction of 41 kcal/day in youth’s daily energy gap. An additional reduction of 120 kcal/day and 23 kcal/day would be needed to reach Healthy People 2010 and Healthy People 2020 goals, respectively. Larger reductions are needed among adolescents and racial/ethnic minority youth.

Conclusions

Aggressive efforts are needed to reverse the positive energy imbalance underlying the childhood obesity epidemic. The energy-gap metric provides a useful tool for goal setting, intervention planning, and charting progress.

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Changing the Future of Obesity: Science, Policy, and Action

Gortmaker SL, Swinburn BA, Levy D, Carter R, Mabry PL, Finegood DT, Huang T, Marsh T, Moodie ML. Changing the future of obesity: Science, policy, and action. Lancet. 2011 Aug 27;378(9793):838-47. doi: 10.1016/S0140-6736(11)60815-5.

Abstract

The global obesity epidemic has been escalating for four decades, yet sustained prevention efforts have barely begun. An emerging science that uses quantitative models has provided key insights into the dynamics of this epidemic, and enabled researchers to combine evidence and to calculate the effect of behaviours, interventions, and policies at several levels–from individual to population. Forecasts suggest that high rates of obesity will affect future population health and economics. Energy gap models have quantified the association of changes in energy intake and expenditure with weight change, and have documented the effect of higher intake on obesity prevalence. Empirical evidence that shows interventions are effective is limited but expanding. We identify several cost-effective policies that governments should prioritise for implementation. Systems science provides a framework for organising the complexity of forces driving the obesity epidemic and has important implications for policy makers. Many parties (such as governments, international organisations, the private sector, and civil society) need to contribute complementary actions in a coordinated approach. Priority actions include policies to improve the food and built environments, cross-cutting actions (such as leadership, healthy public policies, and monitoring), and much greater funding for prevention programmes. Increased investment in population obesity monitoring would improve the accuracy of forecasts and evaluations. The integration of actions within existing systems into both health and non-health sectors (trade, agriculture, transport, urban planning, and development) can greatly increase the influence and sustainability of policies. We call for a sustained worldwide effort to monitor, prevent, and control obesity.

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Quantification of the Effect of Energy Imbalance on Body Weight

Hall KD, Sacks G, Chandramohan D, Chow CC, Wang YC, Gortmaker SL, Swinburn BA. Quantification of the effect of energy imbalance on body weight. Lancet. 2011 Aug 27;378(9793):826-37. doi: 10.1016/S0140-6736(11)60812-X.

Abstract

Obesity interventions can result in weight loss, but accurate prediction of the bodyweight time course requires properly accounting for dynamic energy imbalances. In this report, we describe a mathematical modelling approach to adult human metabolism that simulates energy expenditure adaptations during weight loss. We also present a web-based simulator for prediction of weight change dynamics. We show that the bodyweight response to a change of energy intake is slow, with half times of about 1 year. Furthermore, adults with greater adiposity have a larger expected weight loss for the same change of energy intake, and to reach their steady-state weight will take longer than it would for those with less initial body fat. Using a population-averaged model, we calculated the energy-balance dynamics corresponding to the development of the US adult obesity epidemic. A small persistent average daily energy imbalance gap between intake and expenditure of about 30 kJ per day underlies the observed average weight gain. However, energy intake must have risen to keep pace with increased expenditure associated with increased weight. The average increase of energy intake needed to sustain the increased weight (the maintenance energy gap) has amounted to about 0·9 MJ per day and quantifies the public health challenge to reverse the obesity epidemic.

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Health and Economic Burden of the Projected Obesity Trends in the USA and the UK

Wang YC, McPherson K, Marsh T, Gortmaker SL, Brown M. Health and economic burden of the projected obesity trends in the USA and the UK. Lancet. 2011 Aug 27;378(9793):815-25. doi: 10.1016/S0140-6736(11)60814-3.

Erratum in:
  • Lancet. 2011 Nov 19;378(9805):1778

Abstract

Rising prevalence of obesity is a worldwide health concern because excess weight gain within populations forecasts an increased burden from several diseases, most notably cardiovascular diseases, diabetes, and cancers. In this report, we used a simulation model to project the probable health and economic consequences in the next two decades from a continued rise in obesity in two ageing populations–the USA and the UK. These trends project 65 million more obese adults in the USA and 11 million more obese adults in the UK by 2030, consequently accruing an additional 6-8·5 million cases of diabetes, 5·7-7·3 million cases of heart disease and stroke, 492,000-669,000 additional cases of cancer, and 26-55 million quality-adjusted life years forgone for USA and UK combined. The combined medical costs associated with treatment of these preventable diseases are estimated to increase by $48-66 billion/year in the USA and by £1·9-2 billion/year in the UK by 2030. Hence, effective policies to promote healthier weight also have economic benefits.

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The Global Obesity Pandemic: Shaped by Global Drivers and Local Environments

Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT, Moodie ML, Gortmaker SL. The global obesity pandemic: shaped by global drivers and local environments. Lancet. 2011 Aug 27;378(9793):804-14. doi: 10.1016/S0140-6736(11)60813-1.

Abstract

The simultaneous increases in obesity in almost all countries seem to be driven mainly by changes in the global food system, which is producing more processed, affordable, and effectively marketed food than ever before. This passive overconsumption of energy leading to obesity is a predictable outcome of market economies predicated on consumption-based growth. The global food system drivers interact with local environmental factors to create a wide variation in obesity prevalence between populations. Within populations, the interactions between environmental and individual factors, including genetic makeup, explain variability in body size between individuals. However, even with this individual variation, the epidemic has predictable patterns in subpopulations. In low-income countries, obesity mostly affects middle-aged adults (especially women) from wealthy, urban environments; whereas in high-income countries it affects both sexes and all ages, but is disproportionately greater in disadvantaged groups. Unlike other major causes of preventable death and disability, such as tobacco use, injuries, and infectious diseases, there are no exemplar populations in which the obesity epidemic has been reversed by public health measures. This absence increases the urgency for evidence-creating policy action, with a priority on reduction of the supply-side drivers.

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