Topic: Methods & Modeling

Coffee Chat: Cost-Effective Strategies to Create Healthier Environments: A Walkthrough of the CHOICES National Action Kit 2.0

Posted on November 25, 2024

In this coffee chat hosted by the CHOICES Community of Practice, Jessica Barrett, Senior Research Analyst at the Prevention Research Center on Nutrition and Physical Activity at the Harvard T.H. Chan School of Public Health, demonstrated how to use the CHOICES National Action Kit 2.0, highlighting the metrics that can be compared and where to find more detailed information about a strategy to support the planning and prioritization of health promotion efforts.

View the resource round-up from this coffee chat

Download the November 2024 coffee chat presentation slides

Disclaimer: Our guest speakers share their own perspectives and do not speak for Harvard.

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School-based nutrition education programs alone are not cost effective for preventing childhood obesity: a microsimulation study

Posted on November 12, 2024

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. 2024 Nov 12:S0002-9165(24)00877-3. doi: 10.1016/j.ajcnut.2024.11.006. Epub ahead of print.

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.

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 educationl 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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Coffee Chat: Investing in a Healthier Future: How a Sugary Drink Excise Tax Could Improve Health & Health Equity in Massachusetts

Posted on September 26, 2024

In this coffee chat hosted by the CHOICES Community of Practice, Sara Bleich, Professor of Public Health Policy at the Harvard T.H. Chan School of Public Health and inaugural Vice Provost for Special Projects at Harvard University and Steve Gortmaker, Professor of the Practice of Health Sociology, Director of the Prevention Research Center on Nutrition and Physical Activity, and Director and Co-Principal Investigator of the CHOICES Project at the Harvard T.H. Chan School of Public Health, discussed the progressive health and health equity impacts of a sugary drink excise tax, highlighting recent findings from modeling a statewide tax in Massachusetts.

View the resource round-up from this coffee chat

Download the September 2024 coffee chat presentation slides

Disclaimer: Our guest speakers share their own perspectives and do not speak for Harvard.

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Report: Sugary Drink Excise Tax in Boston, MA

Posted on September 25, 2024

Mom giving glass of water to young daughter

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

Executive Summary

Sugary drink consumption has been linked to excess weight gain, obesity, incidence of type 2 diabetes, heart disease, and cancer. Federal, state, and local governments have considered implementing excise taxes on sugary drinks to reduce consumption, prevent obesity, and provide a new source of government revenue.^1-3In Massachusetts, legislative measures to introduce a tiered sugary drink excise tax have been proposed.^4,5The most recent proposed bills specify that tax revenue be dedicated to benefits, services, and programs, including universal free school meals and provision of healthy meals in Head Start and other high need early education settings, for communities most impacted by health inequity and burdened by chronic health outcomes related to sugary drink consumption.^4,5

We modeled the impact of a statewide excise tax on sugary drinks on health outcomes among Boston residents. Consistent with current policy proposals, we assumed tiered tax rates depending on the sugar content of the beverage: $0.01/ounce for beverages with more than 7.5 but less than 30 grams of sugar per 12 fluid ounces and $0.02 for beverages with more than 30 grams of sugar per 12 fluid ounces. CHOICES cost-effectiveness analysis compared the costs and outcomes of implementing a tax with the costs and outcomes expected if the tax were not implemented over 10 years (2023-2032).

The sugary drink excise tax on distributors is projected to be cost-saving. This means that the tax would save more in future healthcare costs than it would cost to implement. This is without consideration of the potential revenue that would be generated, where a tiered $0.01-$0.02/ounce statewide excise tax on sugary drinks in Massachusetts could raise as much as $226 million to $322 million in annual revenue.⁶Among Boston residents, the tax is projected to decrease sugary drink consumption, prevent more than 6,000 cases of obesity, and save $91.2 million in health care costs. People who consume sugary drinks are projected to spend less on these drinks with the excise tax in place. We also project that Black and Hispanic/Latinx Boston residents will experience a greater reduction in obesity rates compared with White, non-Hispanic/Latinx residents after the tax is implemented. These results are summarized below and in the complete report. Projected results for a $0.02/ounce state excise tax based on the volume of sugary drinks were similar.

Continue reading in the full report.

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

Citation

McCulloch SM, Barrett JL, Reiner JF, Cradock AL, Gortmaker SL. Boston: Sugary Drink Excise Tax. CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; February 2024. For more information, please visit www.choicesproject.org.

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

Funding

This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376), and the National Institutes for Health (R01HL146625). 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.

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

References

American Public Health Association Taxes on Sugar-Sweetened Beverages. 2012.
Falbe J, Rojas N, Grummon AH, Madsen KA. Higher Retail Prices of Sugar-Sweetened Beverages 3 Months After Implementation of an Excise Tax in Berkeley, California. American Journal of Public Health. 2015;105(11):2194-2201.
World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013–2020 [Internet]. Geneva: WHO. Updated appendix 3, “Best buys” and other recommended interventions for the prevention and control of noncommunicable diseases; [updated 2017; cited 2019 Sep 17]. Available from: https://iris. who.int/bitstream/handle/10665/94384/9789241506236_eng.pdf?sequence=1
Massachusetts Senate Docket No. 959. An Act to promote healthy alternatives to sugary drinks. https://malegislature.gov/Bills/193/SD959. Filed January 18, 2023. Accessed March 9, 2023.
Massachusetts House Docket No. 1813. An Act to promote healthy alternatives to sugary drinks. https://malegislature.gov/Bills/193/HD1813. Filed January 18, 2023. Accessed March 9, 2023.
UCONN Rudd Center. Revenue Calculator for Sugary Drink Taxes. Release: April 13, 2021. http://www.uconnruddcenter.org/revenue-calculator-for-sugary-drink-taxes. Accessed December, 2023.

See the report for the full list of references.

See the sugary drink excise tax report for the impact on the Massachusetts population.

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Report: Sugary Drink Excise Tax in Massachusetts

Posted on September 25, 2024

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

Executive Summary

We modeled implementation of a state excise tax on sugary drinks in Massachusetts. Consistent with current policy proposals, we assumed tiered tax rates depending on the sugar content of the beverage: $0.01/ounce for beverages with more than 7.5 but less than 30 grams of sugar per 12 fluid ounces and $0.02 for beverages with more than 30 grams of sugar per 12 fluid ounces. CHOICES cost-effectiveness analysis compared the costs and outcomes of implementing a tax with the costs and outcomes expected if the tax were not implemented over 10 years (2023-2032).

The sugary drink excise tax on distributors is projected to be cost-saving. This means that the tax would save more in future health care costs than it costs to implement. This is without consideration of the potential revenue that would be generated, where a tiered $0.01-$0.02/ounce statewide excise tax on sugary drinks in Massachusetts could raise as much as $226 million to $322 million in annual revenue.⁶Among Massachusetts residents, the tax is projected to decrease sugary drink consumption, prevent over 62,000 of cases of obesity, and save $937 million in health care costs. People who consume sugary drinks are projected to spend less on these drinks with the excise tax in place. We also project that Black and Hispanic/Latinx Massachusetts residents will experience a greater than average reduction in obesity levels after the tax is implemented, leading to improved health equity. These results are summarized below and in the complete report. Projected results for a $0.02/ounce state excise tax based on the volume of sugary drinks were similar.

Continue reading in the full report.

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

Citation

McCulloch SM, Barrett JL, Reiner JF, Cradock AL, Gortmaker SL. Massachusetts: Sugary Drink Excise Tax. The CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; February 2024. For more information, please visit www.choicesproject.org.

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

Funding

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

References

American Public Health Association Taxes on Sugar-Sweetened Beverages. 2012.
Falbe J, Rojas N, Grummon AH, Madsen KA. Higher Retail Prices of Sugar-Sweetened Beverages 3 Months After Implementation of an Excise Tax in Berkeley, California. American Journal of Public Health. 2015;105(11):2194-2201.
World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013–2020 [Internet]. Geneva: WHO. Updated appendix 3, “Best buys” and other recommended interventions for the prevention and control of noncommunicable diseases; [updated 2017; cited 2019 Sep 17]. Available from: https://iris. who.int/bitstream/handle/10665/94384/9789241506236_eng.pdf?sequence=1
Massachusetts Senate Docket No. 959. An Act to promote healthy alternatives to sugary drinks. https://malegislature.gov/Bills/193/SD959. Filed January 18, 2023. Accessed March 9, 2023.
Massachusetts House Docket No. 1813. An Act to promote healthy alternatives to sugary drinks. https://malegislature.gov/Bills/193/HD1813. Filed January 18, 2023. Accessed March 9, 2023.
UCONN Rudd Center. Revenue Calculator for Sugary Drink Taxes. Release: April 13, 2021. http://www.uconnruddcenter.org/revenue-calculator-for-sugary-drink-taxes. Accessed December, 2023.

See the report for the full list of references.

See the sugary drink excise tax report for the impact on the Boston, MA population.

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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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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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The Societal Costs and Health Impacts on Obesity of BMI Report Cards in US Schools

Posted on July 3, 2023

This study aims to estimate the 10-year cost-effectiveness of school-based BMI report cards, a commonly implemented program for childhood obesity prevention in the US.

Poole MK, Gortmaker SL, Barrett JL, McCulloch SM, Rimm EB, Emmons KM, Ward ZJ, Kenney EL. The Societal Costs and Health Impacts on Obesity of BMI Report Cards in US Schools. Obesity (Silver Spring). 2023 Aug;31(8):2110-2118. doi: 10.1002/oby.23788. Epub 2023 Jul 3.

Abstract

Objective: This study aimed to estimate the 10-year cost-effectiveness of school-based BMI report cards, a commonly implemented program for childhood obesity prevention in the US where student BMI is reported to parents/guardians by letter with nutrition and physical activity resources, for students in grades 3 to 7.

Methods: A microsimulation model, using data inputs from evidence reviews on health impacts and costs, estimated: how many students would be reached if the 15 states currently measuring student BMI (but not reporting to parents/guardians) implemented BMI report cards from 2023 to 2032; how many cases of childhood obesity would be prevented; expected changes in childhood obesity prevalence; and costs to society.

Results: BMI report cards were projected to reach 8.3 million children with overweight or obesity (95% uncertainty interval [UI]: 7.7-8.9 million) but were not projected to prevent any cases of childhood obesity or significantly decrease childhood obesity prevalence. Ten-year costs totaled $210 million (95% UI: $30.5-$408 million) or $3.33 per child per year with overweight or obesity (95% UI: $3.11-$3.68).

Conclusions: School-based BMI report cards are not cost-effective childhood obesity interventions. Deimplementation should be considered to free up resources for implementing effective programs.

Funding

The JPB Foundation; National Cancer Institute, Grant/Award Number: 3P50CA244433; National Institute of Diabetes and Digestive and Kidney Diseases, Grant/Award Number:DK 007703-22; Robert Wood Johnson Foundation, Grant/Award Number: 2833590; National Heart, Lung, and Blood Institute, Grant/Award Number: 1F31HL162250-01A1.

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