Topic: Sugary Drinks

Cost-Effectiveness Analysis & Stakeholder Evaluation of 2 Obesity Prevention Policies in Maine, US

The CHOICES team partnered with the Maine-Harvard Prevention Research Center and the Maine Obesity Policy Committee to evaluate two state-level obesity prevention strategies– a sugar-sweetened beverage (SSB) excise tax and a policy removing SSBs as SNAP-eligible products. Both policies were estimated to save society more than they cost to implement. However, the SNAP restriction raised greater equity concerns among stakeholders.

Long MW, Polacsek M, Bruno P, Giles CM, Ward ZJ, Cradock AL, Gortmaker SL. Cost-Effectiveness Analysis and Stakeholder Evaluation of 2 Obesity Prevention Policies in Maine, US. J Nutr Educ Behav. 2019 Aug [Epub ahead of print], pii: S1499-4046(19)30922-4.

Obesity prevention is a priority item for many policymakers at the state level. The goal of this study was to not only predict the health impact of two obesity prevention policies in Maine, but also to gauge stakeholder interest and level of support for these policies.

Two obesity prevention policies were focused on:

– A $0.01/ounce sugar-sweetened beverage (SSB) excise tax for the state of Maine
– A Supplemental Nutrition Assistance Program (SNAP) policy that would not allow SSBs to be bought using SNAP money (SNAP SSB restriction policy)

The stakeholder engagement process developed over more than 10 years as a result of a relationship between the Maine Obesity Policy Committee (Maine OPC) and the Maine-Harvard Prevention Research Center (MHPRC). The Maine OPC consists of individuals from the Maine Public Health Association, American Heart Association of Maine, American Cancer Society, the State Department of Health and Human Services, legislators, lobbyists, and health systems. The stakeholder interview process was conducted in two phases: Phase 1 in 2013 focused on an SSB excise tax and Phase 2 in 2016 focused on a SNAP SSB restriction policy.

The study authors also measured the health impact of these two policies on a virtual population that was developed for the state of Maine. The CHOICES model was used to project these policies’ impact on obesity prevalence and health care costs over 10 years (2017-2027).

The results from the CHOICES model showed the potential for both health improvement and cost-savings. In particular:

Metric*

$0.01/ounce SSB excise tax

SNAP SSB restriction policy

Health care cost savings
$78.3 million $15.3 million
Quality-adjusted life years (QALYs) saved
3,560 749

*For metric definitions, please visit the CHOICES Modeled Outputs Glossary

Study authors noted mixed levels of support for each policy by Maine stakeholders, with less support for the SNAP SSB restriction policy. Opposition to the SNAP restriction policy was based on concern that SNAP recipients were being unfairly targeted and stigmatized. This study used strategic science thinking to inform obesity prevention policy in Maine by strengthening the capacity of existing stakeholder groups and local applied researchers to integrate advanced cost-effectiveness modeling into their already well-developed policy input process. Results of the modeling were presented to the state’s legislature, which was holding hearings on a proposed SSB tax. This study points to the need for stronger, long-term partnerships between local public health researchers, cost-effectiveness modeling groups, and local policy stakeholder groups.

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Report: Cost-Effectiveness of a Sugary Drink Excise Tax in Denver

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

Executive Summary

Continually rising rates of obesity represent one of the greatest public health threats facing the United States. Obesity has been linked to excess consumption of sugary drinks. Federal, state, and local governments have considered implementing excise taxes on sugary drinks to reduce consumption, reduce obesity and provide a new source of government revenue.1-4

We modeled implementation of a city excise tax, a tax on sugary drinks only, at a tax rate of $0.02/ounce.

The tax model was projected to be cost-saving and resulted in lower levels of sugary drink consumption, thousands of cases of obesity prevented, and hundreds of millions of dollars in health care cost savings. Health care cost savings per dollar invested was $11 in the model.

Background 

Although sugary drink consumption has declined in recent years, adolescents and young adults in the United States consume more sugar than the Dietary Guidelines for Americans 2015-2020 recommends, with persistent racial/ethnic disparities.5-9 According to recent estimates, 26% of adults and 21% of youth in Denver drink at least one soda or other sugary drink per day.10,11 Public health researchers have suggested that excess intake of sugary drinks may be one of the single largest drivers of the obesity epidemic in the U.S.12 An estimated 57% of adults and nearly 30% of children ages 2-17 in Denver have overweight or obesity.10,13

Targeted marketing contributes to differences in consumption by race/ethnicity group. Black youth are twice as likely to see TV ads for sugary drinks as White non-Hispanic youth.14 Hispanic and Black youth are a target growth market for sugary drinks. On the other hand, Black and Hispanic youth are less likely to be the audience for company marketing of more healthy beverage alternatives, like water.15 Consumption of sugary drinks increases the risk of chronic diseases through changes in body mass index (BMI), insulin regulation, and other metabolic processes.16-18 Randomized intervention trials and longitudinal studies have linked increases in sugary drink consumption to excess weight gain, diabetes, cardiovascular disease, and other health risks.16,17 There are persistent racial and ethnic disparities across both sugary drink consumption levels and rates of obesity and chronic disease.5-8 In light of this evidence, the Dietary Guidelines for Americans 2015-20209 recommends that individuals limit sugary drink intake in order to manage body weight and reduce risk of chronic disease.

Taxation has emerged as one recommended strategy to reduce consumption of sugary drinks.12,19 This strategy has been studied by public health experts, who have drawn on the success of tobacco taxation and decades of economic research to model the estimated financial and health impact of an sugary drink excise tax.20-23 Sugary drinks include all drinks with added caloric sweeteners. Proposed and enacted sugary drink excise taxes typically do not apply to 100% juice or milk products. This report aims to model the projected effect of sugary drink excise taxes on health and disease outcomes over the next decade.

Modeling Framework: How excise taxes can lead to better health

Increased local excise tax is linked to change in BMI through change in sugary drink price and consumption

Logic Model for Sugar Sweetened Beverage Tax

How does increasing the price of sugary drinks change individual sugary drink consumption?

The first portion of the logical model above, highlighting excise tax and drink price.Since the cost of a sugary drink excise tax is incorporated directly into the beverage’s sticker price, an excise tax will likely influence consumer purchasing decisions more than a comparable sales tax that is added onto the item at the register. We assume 100% pass-through of the tax over 10 years and assume the tax rate would be adjusted annually for inflation. Our pass-through rate estimate is supported by empirical studies of excise taxes in Mexico and France that demonstrate near-complete pass through rates to consumers.24 Short term studies for the local tax in Berkeley indicate imperfect, or less than 100%, pass-through.3,25,26 The expected change in sugary drink price was estimated using an average of $0.06/ounce based on national sugary drink prices.27 The price per ounce in this study was based on a weighted average of sugary drink consumption across stores, restaurants and other sources according to the estimates from the National Health and Nutrition Examination Survey (NHANES) 2009-2010. The price per ounce of sugary drinks purchased in stores was calculated using weighted averages of two-liter bottles, 12-can cases, and single-serve containers based on 2010 Nielsen Homescan data.27 For example, a $0.02/ounce tax would raise the price of a 12-ounce can of soda from $0.72 to $0.96/can post-tax.

The middle portion of the Logic Model above, highlighting drink price and and drink consumption.How does an excise tax on distributors affect the price paid by consumers?

We used local age and race/ethnicity specific estimates of adult sugary drink consumption from the Colorado Behavioral Risk Factor Surveillance System10 and youth sugary drink consumption from the Healthy Kids Colorado Survey28 to adjust national estimates of sugary drink consumption from NHANES 2011-2014 to estimate current sugary drink consumption levels in Denver. The mean own-price elasticity of demand for sugar-sweetened soft drinks (not including diet) is -1.21.29 Recent research on the Berkeley tax indicating a 21% reduction in sugary drink intake among low income populations supports this estimate.25

The final part of the Logic Model, highlighting drink consumption and BMI.

What are the individual health effects of decreasing sugary drink consumption?

Research has shown that decreasing sugary drink consumption can have positive effects on health in adults and youth. We conducted evidence reviews for the impact of a change in sugary drink intake on BMI, accounting for dietary compensation.23 Four large, multi-year longitudinal studies in adults17,30-32 were identified. The relationship was modeled using a uniform distribution based on the range of estimated effects on BMI due to reducing sugary drink intake; a one-serving reduction was associated with a BMI decrease of 0.57 in adults. Among youth, a double-blind randomized controlled trial conducted over 18 months found that an additional 8 ounce serving of sugary drinks led to a 2.2 lbs greater weight gain.33

Reach

The intervention applies to all youth and adults in Denver. However, the model only looks at the effects on those 2 years of age and older.*

*BMI z-scores were used in our analyses, which are not defined for children under 2 years of age.

Cost

We assume the tax will incur start up and ongoing labor costs for tax administrators in the Denver Department of Finance. To implement the intervention, the Denver Department of Finance would need to process tax statements and conduct audits. Businesses would also need to prepare tax statements and participate in audits, which would require labor from private tax accountants. Cost information was drawn from localities with planned or implemented excise taxes on soft drinks.22,23 The cost and benefit estimates do not include expected tax revenue.

CHOICES Microsimulation Model

The CHOICES microsimulation model for Denver was used to calculate the costs and effectiveness over 10 years (2017–27). Cases of obesity prevented were calculated at the end of the model period in 2027. The model was based on prior CHOICES work23,34, and created a virtual population of Denver residents using data from: U.S. Census, American Community Survey, Behavioral Risk Factor Surveillance System10,16, NHANES, National Survey of Children’s Health35, the Medical Expenditure Panel Survey, multiple national longitudinal studies, and obesity prevalence data provided by Denver Public Health and Denver Health and Hospital Authority. Using peer-reviewed methodology, we forecasted what would happen to this virtual population with and without a sugary drink tax to model changes in disease and mortality rates, and health care costs due to the tax.

An infographic outline of the study's basic methodology.

Results: $0.02/ounce City Excise Tax on Sugary Drinks

Overall, the model shows that a sugary drink excise tax is cost-saving. Compared to the simulated natural history without a tax, the tax is projected to result in lower levels of sugary drink consumption, fewer cases of obesity, fewer deaths, and health care savings greater than $33 million dollars over the 10-year period under consideration.

The estimated reduction in obesity attributable to the tax leads to lower projected health care costs, offsetting tax implementation costs and resulting in net cost savings. The difference between total health care costs with no intervention and lower health care costs with an intervention represent health care costs saved; these savings can be compared to the cost of implementing the tax to arrive at the metric of health care costs saved per $1 invested.

An infographic outlining the results of the 2 cent excise tax on sugary drinks.

 

Outcome $0.02/ounce excise tax
Mean
(95% uncertainty interval)
10 Year Reach* 963,000
(960,000; 965,000)
First Year Reach* 733,000
(732,000; 734,000)
Decrease in 12-oz Serving of Sugary Drinks per Person in First Year* 75.2
(43.9; 158)
Mean Reduction in BMI Units per Person* -0.146
(-0.400; -0.0451)
10 Year Intervention Implementation Cost per Person $3.20
($3.19; $3.20)
Total Intervention Implementation Cost Over 10 Years $3,080,000
($3,080,000; $3,080,000)
Annual Intervention Implementation Cost $308,000
($308,000; $308,000)
Health Care Costs Saved Over 10 Years $33,900,000
($10,400,000; $90,800,000)
Net Costs Difference Over 10 Years -$30,800,000
(-$87,800,000; -$7,310,000)
Quality Adjusted Life Years (QALYs) Gained Over 10 Years 1,320
(406; 3,560)
Years of Life Gained Over 10 Years 250
(66; 665)
Deaths Prevented Over 10 Years* 78
(21; 204)
Years with Obesity Prevented Over 10 Years 36,600
(11,500; 97,500)
Health Care Costs Saved per $1 Invested Over 10 Years $11.01
($3.38; $29.50)
Cases of Obesity Prevented in 2027* 5,575
(1,760; 14,800)
Cases of Childhood Obesity Prevented in 2027* 951
(316; 2,470)
Cost per Year with Obesity Prevented Over 10 Years Cost-saving
Cost per QALY Gained Over 10 Years Cost-saving
Cost per YL Gained Over 10 Years Cost-saving
Cost per Death Averted Over 10 Years Cost-saving

Uncertainty intervals are estimated by running the model 1,000 times, taking into account both uncertainty from data sources and virtual population projections, and calculating a central range in which 95 percent of the model results fell.

All metrics reported for the population over a 10-year period and discounted at 3% per year, unless otherwise noted.

*Not discounted.

 

There are differences in sugary drink consumption and obesity prevalence by race/ethnicity in Denver. The CHOICES model used local data to build a virtual Denver population. Without any intervention:

Sugary drink consumption is highest in the Hispanic population

A bar graphing showing the Pre-tax Sugary Drink Consumption by Race and Ethnicity. Non-Hispanic white averages 4.12 ounces. Non-Hispanic black averages 5.52 ounces. Hispanic averages 9.45 ounces. Other averages 6.04 ounces. Denver's average is 6.27.

Obesity prevalence is highest in the Non-Hispanic Black and Hispanic populations

A graph showing obesity prevalence is highest in the Non-Hispanic Black and Hispanic populations.

Results: $0.02/ounce City Excise Tax on Sugary Drinks by Race/Ethnicity Groups

Outcome Non-Hispanic White
Mean
(95% uncertainty interval)
Non-Hispanic Black
Mean
(95% uncertainty interval)
Hispanic
Mean
(95% uncertainty interval)
Other
Mean
(95% uncertainty interval)
Decrease in 12-oz Serving of Sugary Drinks per Person in First Year* 49.5
(28.8; 103)
66.3
(38.7; 140)
113
(66.2; 238)
72.5
(42.2; 152)
Reduction in Obesity Prevalence 0.28%
(0.09%; 0.75%)
0.56%
(0.17%; 1.53%)
1.09%
(0.35%; 2.93%)
0.45%
(0.13%; 1.19%)
QALYS Gained Over 10 Years 352
(106; 964)
137
(41; 369)
762
(231; 2,040)
66
(17; 185)
Years of Life Gained Over 10 Years 90
(19; 263)
34
(5; 97)
108
(22; 294)
18
(0; 53)
Years with Obesity Prevented Over 10 Years 8,030
(2,500; 21,700)
3,220
(993; 8,860)
23,700
(7,490; 63,800)
1,690
(511; 4,540)
Cases of Obesity Prevented in 2027* 1,200
(376; 3,240)
479
(145; 1,320)
3,640
(1,160; 9,760)
256
(76; 681)
Cases of Childhood Obesity Prevented in 2027* 146
(48; 397)
92
(30; 244)
663
(219; 1,760)
50
(15; 138)

Uncertainty intervals are estimated by running the model 1,000 times, taking into account both uncertainty from data sources and virtual population projections, and calculating a central range in which 95 percent of the model results fell.

All metrics reported for the population over a 10-year period and discounted at 3% per year, unless otherwise noted.

*Not discounted.

Communities of color make up:

53% of Denver's total population in 2027 79% of projected total cases of obesity prevented in 2027 from $0.02 per ounce excise tax on sugary drinks
Race/Ethnicity Group % of Total Population Total Number of Cases of Obesity Prevented in 2027 % of Total Number of Cases of Obesity Prevented in 2027
Non-Hispanic White 47% 1,200 21%
Hispanic 37% 3,640 65%
Non-Hispanic Black 10% 479 9%
Other 6% 256 5%
Total 100% 5,575 100%

A $0.02/ounce excise tax on sugary drinks is projected to have a greater health impact on Non-Hispanic Black and Hispanic communities in Denver

Bar graph showing the percentage point reduction in obesity prevalence by race or ethnic group. Non-Hispanic white shows a 0.28% difference. Non-hispanic black shows a 0.56% difference. Hispanice shows a 1.09% difference. Other shows a 0.45% difference.

 

Impact on Diabetes

We estimated the impact of the tax-induced reduction in sugary drink intake on diabetes incidence for adults ages 18-79 years using a published meta-analysis of the relative risk of developing diabetes due to a one-serving change in sugary drink consumption36 as well as local estimates of diabetes. On average, each 8.5 ounce serving of sugary drinks per day increases the risk of diabetes by 18%.36

In Denver, we estimated that the proposed sugary drink excise tax would lead to a 7% reduction in diabetes incidence in the sugary drink tax model. Impact on diabetes incidence was calculated over a one-year period once the tax reaches its full effect. Impact on diabetes was calculated based on summary results from the model, not directly via microsimulation.

Infographic showing a $0.02 per ounce tax on sugary drinks leads to a 7% reduction in diabetes, 302 prevented cases of diabetes, $882,000 dental decay treatment cost savings over 10 years via Medicaid and $4 million societal savings in dental decay treatment costs over 10 years.

Impact on Tooth Decay

We estimated the impact of a sugary drink excise tax on tooth decay cost using a longitudinal analysis of the relationship between intake of sugars and tooth decay in adults. On average, for every 10 grams higher intake of sugar per day, there is an increase in decayed, missing and filled teeth (DMFT) of approximately 0.10 over 10 years.37 As described above, we assume that the excise tax will result in a reduction in sugary drink intake. There are many studies showing a similar relationship between higher intake of sugars and tooth decay in children and youth38 and thus we assume the same relationship as found in adults.

We used 2018 Health First Colorado Dental Fee Schedule39 data to estimate a Medicaid cost of treating DMFT as: $232.28 for a permanent crown and $83.59 for a filling. These codes reflect treatment for one surface and do not reflect higher reimbursement rates for multi-surface treatment, temporary crowns, or potential flat tax schedules. Based on analysis of data on tooth decay, fillings and crowns for the U.S. population from NHANES 1988-1994 (the last year crowns and fillings were separately reported)40, we estimate that 78.9% of tooth decay in children and 43.5% of tooth decay in adults is treated. Using this same data set, we estimate that 97.5% of treatment for children is fillings and 82.5% of treatment for adults is fillings.

To estimate Medicaid-specific dental caries cost savings, we used local estimates of the numbers of people enrolled in Medicaid and the proportion receiving Medicaid dental services. Because of limited Medicaid dental coverage for adults in Denver, only children are included in the Medicaid-specific calculations. In Denver, we estimated that a $0.02/ounce tax would lead to a total DMFT savings of $882,000 in Medicaid savings over a period of 10 years. The Medicaid reimbursement tax estimates may underestimate the total cost savings of tooth decay treatment projected here as dental providers may charge higher amounts to patients.

Considerations for Health Equity

Concerns have been raised regarding the impact of the tax on households with low income households. For many goods, including cigarettes, low-income households are more price-sensitive than high-income peers. If this is also true for low-income sugary drink consumers, these households would spend less on sugary drinks after the tax goes into effect, which would free up disposable income for other consumer purchases.41 Using sales data from the Rudd Center Sugary Beverage calculator42, we project that individuals and households in Denver will spend less money on sugary drinks after the tax.

In addition, low-income consumers on average consume more sugary drinks than higher income consumers. We therefore project that greater health benefits from this policy will accrue to these consumers; the same is true for a number of racial and ethnic groups (see pages 9-10). Using data from NHANES and Denver on sugary drink consumption in the CHOICES model, the average daily consumption of sugary drinks by people in Denver varies by racial and ethnic group (see page 8). Under the proposed tax, Hispanic Denver residents are projected to experience a fourfold reduction in obesity prevalence compared to White non-Hispanic Denver residents. Similarly, the reduction in obesity prevalence among Black non-Hispanic Denver is projected to be almost twice as high as the reduction among White non-Hispanic Denver residents. On that basis, the proposed tax should tend to decrease disparities in obesity outcomes.

Infographic showing a 2 cent per ounce tax on sugary drinks leads to $51.10 less spending on sugary drinks per individual, $118 less spending per household and $20.6 less spending overall in Denver in the first year.

Implementation Considerations

Revenue raised from a sugary drink tax can be reinvested in low-income communities. For instance, in Berkeley, CA, sugary drink tax revenue has been allocated for spending on school and community programs to promote healthy eating, diabetes and obesity prevention; many serve low-income or minority populations.43,44 Public support for such taxes generally increases with earmarking for preventive health activities.44

There is opposition from the food and beverage industry, which spends billions of dollars promoting their products.45 Relatively small beverage excise taxes are currently applied across many states. The proposed tax is likely to be sustainable if implemented based on the successful history of tobacco excise taxes. There is potential for a shift in social norms of sugary drink consumption based on evidence from tobacco control tax and regulatory efforts.46 This shift in norms can be facilitated by taxing sugary beverages, which increases the attractiveness of non-caloric beverages options and discourages consumers from selecting any soft drink options when making beverage decisions.

Conclusion

We project that a tax policy in Denver will prevent thousands of cases of childhood and adult obesity, prevent new cases of diabetes, increase healthy life years and save more in future health care costs than it costs to implement. Revenue from the tax can be used for education and health promotion efforts. Implementing the tax could also serve as a powerful social signal to reduce sugar consumption.

Citation

Moreland J, Kraus (McCormick) E, Long MW, Ward ZJ, Giles CM, Barrett JL, Cradock AL, Resch SC, Greatsinger A, Tao H, Flax CN, and Gortmaker SL. Denver: Sugary Drink Excise Tax. The CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; December 2018.

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

Funding

This work is supported by The JPB Foundation. This report is intended for educational use only. Results are those of the authors and not the funders.

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

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  41. Farrelly MC, Bray JW. Response to increases in cigarette prices by race/ethnicity, income, and age groups – United States, 1976-1993 (Reprinted from MMWR, vol 47, pg 605-609, 1998). JAMA-J Am Med Assoc. 1998;280(23):1979-1980.
  42. UCONN Rudd Center. Revenue Calculator for Sugar-Sweetened Beverage Taxes. 2014; http://www.uconnruddcenter.org/revenue-calculator-for-sugary-drink-taxes. Accessed March, 2016.
  43. Lynn J. City Council votes to allocate ‘soda tax’ revenue to school district, city organizations. The Daily Californian. Jan. 20, 2016, 2016.
  44. Friedman R. Public Opinion Data, 2013. New Haven, CT: Yale Rudd Center for Food Policy & Obesity; 2013.
  45. Federal Trade Commission. A review of food marketing to children and adolescents: follow-up report. Washington, DC Dec 2012 2012.
  46. Frieden TR, Mostashari F, Kerker BD, Miller N, Hajat A, Frankel M. Adult tobacco use levels after intensive tobacco control measures: New York City, 2002-2003. American Journal of Public Health. 2005;95(6):1016-1023.

 

Brief: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) Intervention in West Virginia

The information in this brief is intended for educational use only.

This brief provides a summary of the CHOICES Learning Collaborative Partnership simulation model of integrating Key 2 a Healthy Start, West Virginia’s implementation of Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC), into the state’s Tiered Reimbursement system, which provides subsidy incentives to child care centers meeting quality standards.

The Issue

Over the past four decades, childhood obesity has tripled.1 In WV, obesity rates in 2-4 year old WIC participants increased from 14% up to 16.4% in 2014.2 WV was one of four states that experienced increasing rates in this young population. Now labeled as an epidemic, health care costs for treating obesity-related health conditions such as heart disease and diabetes range from $147 billion to $210 billion per year.3 While multiple strategies are needed to reverse the epidemic, emerging prevention strategies directed at children show great promise for addressing the epidemic.4 A large body of evidence shows that healthy eating, physical activity, and limiting sugary drinks and screen time helps kids grow up at a healthy weight.

In West Virginia, 41% of 2-5 year olds attend a licensed child care center. Licensed centers can offer healthy, nurturing environments for children. Tiered Reimbursement can encourage and empower centers to voluntarily improve nutrition, physical activity, and screen time standards while increasing financial incentives.

About Key 2 A Healthy Start

Key 2 a Healthy Start is based on NAP SACC, an evidence-based intervention for helping child care centers attain best practices regarding nutrition, active play, and screen time.5,6 The program enables child care directors and staff to complete self-assessments of their nutrition, active play, and screen time practices and receive training and technical assistance to implement changes that create healthier environments and policies. Integrating Key 2 a Healthy Start into West Virginia’s Tiered Reimbursement system would incentivize and support participation in the intervention and broaden its availability.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of integrating Key 2 a Healthy Start into Tiered Reimbursement over 10 years versus the costs and outcomes of not implementing the intervention. This model assumes that 44% of licensed child care centers will participate in Tiered Reimbursement and thus participate in Key 2 a Healthy Start.

Implementing Key 2 a Healthy Start in child care centers throughout West Virginia is an investment in the future:If Key 2 a Healthy Start in child care centers were implemented throughout West Virginia, then over 38,000 children would be reached with healthier food and drinks, more active play, and less screen time over 10 years; 593 cases of childhood obesity would be prevented in 2025 (the final year of the model), and it would cost $69.80 per child to implement.

Conclusions and Implications

Every child deserves a healthy start in life. This includes ensuring that all kids have access to healthy foods and drinks and to be physically active, no matter where they live or which child care they attend. A state-level initiative to bring Key 2 a Healthy Start to West Virginia’s child care centers through the Tiered Reimbursement system could prevent 593 cases of childhood obesity in the last year of the model. Additionally, healthy child care environments and policies would be implemented for over 38,000 children.

For every $1.00 spent on implementing Key 2 a Healthy Start, a savings of $0.10 in health care costs is estimated. These results reinforce the importance of Key 2 a Healthy Start as primary obesity prevention. Implementing small changes early for young children can help them develop healthy habits for life, thereby avoiding more costly and ineffective treatment options in the future.

Evidence is growing about how to help children achieve a healthy weight. Programs such as Key 2 a Healthy Start are laying the foundation for healthier futures by helping child care centers create environments and policies that nurture healthy habits. Leaders at the federal, state, and local level should use the best available evidence to determine which evidence-based interventions hold the most promise for children to develop and maintain a healthy weight.

References

  1. Fryar CD, Carroll MD, Ogden CL, Prevalence of overweight and obesity among children and adolescents: United States, 1963-1965 through 2011-2012. Atlanta, GA: National Center for Health Statistics, 2014.
  2. Pan L, Freedman DS, Sharma AJ, et al. Trends in Obesity Among Participants Aged 2-4 Years in the Special Supplemental Nutrition Program for Women, Infants, and Children – United States, 2000–2014. Morbidity and Mortality Weekly Report (MMWR) 2016;65:1256–1260. DOI.
  3. Gortmaker SL, Wang YC, 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 (Millwood). 2015 Nov;34(11):1932-9.
  4. West Virginia Bureau of Children and Families (2015).
  5. Ward DS, Benjamin SE, Ammerman AS, Ball SC, Neelon BH, Bangdiwala SI. Nutrition and physical activity in child care: results from an environmental intervention. Am J Prev Med. 2008 Oct;35(4):352-6.
  6. Alkon A, Crowley AA, Neelon SE, Hill S, Pan Y, Nguyen V, Rose R, Savage E, Forestieri N, Shipman L, Kotch JB. Nutrition and physical activity randomized control trial in child care centers improves knowledge, policies, and children’s body mass index. BMC Public Health. 2014 Mar 1;14:215.
Suggested Citation:

Jeffrey J, Giles C, Flax C, Cradock A, Gortmaker S, Ward Z, Kenney E. West Virginia Key 2 a Healthy Start Intervention [Issue Brief]. West Virginia Department of Health and Human Resources, Charleston, WV, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; April, 2018.

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the West Virginia Department of Health and Human Resources through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only.

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Report: Cost-Effectiveness of a Sugary Drinks Excise Tax in Alaska

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

Intervention Strategy Description

Implementation of a state excise tax on sugary drinks based on either solely the size of the beverage (“volume tax”; $0.03/ounce) or both beverage size and sugar content (“graduated tax”: $0.03/ounce for higher-sugar-content beverages and $0.02/ounce for lower-sugar-content beverages). The tax in either form would be applied at the wholesale level, be administered by the state and be based on proposals considered by federal, state, and local governments and the American Heart Association.1‐4

Background 

Summary Results of Sugar-Sweetened Beverage Excise Tax in AlaskaSugary drinks include all beverages with added caloric sweeteners. The modeled excise tax does not apply to 100% juice, milk products, or artificially-sweetened beverages. Although sugary drinks consumption has declined in recent years, adolescents and young adults in the United States consume more sugar than the Dietary Guidelines for Americans recommend, with persistent racial/ethnic disparities.5-8 Randomized trials and longitudinal studies have linked sugary drinks consumption to excess weight gain, diabetes, and cardiovascular disease. Consumption of sugary drinks increases the risk of chronic diseases through its impact on weight and other mechanisms.9,10 The Dietary Guidelines for Americans, 2015-202011 recommend that individuals reduce sugary drink intake in order to manage their body weight. Drawing on the success of tobacco taxation and decades of economic research, public health experts have studied taxes on sugary drinks and documented their likely impact.12-15 In 2009, the IOM recommended that local governments implement tax strategies to reduce consumption of “calorie-dense, nutrient-poor foods,” emphasizing sugary drinks as an appropriate target for taxation.16

Modeled Tax Structures

In recent years, 7 cities in the U.S. have passed and implemented taxes of varying amounts on sugary drinks based on the size of the beverage (referred to in this brief as a volume tax). The volume tax model in this brief followed this approach.

The United Kingdom is applying a different type of tax structure to a sugary drink tax starting in 2018, which will be a tax rate that varies according to both the amount of sugar in the beverage and the size of the beverage, referred to in this brief as a graduated tax. This approach, according to a recent report by the Urban Institute, may encourage industry to reformulate products to reduce sugar.17 The American Heart Association has developed a proposal for a graduated tax structure; that framework was used for the graduated tax model.1

Chart summarizing results of Graduated Tax Approach

Under both approaches, a tax rate of 0.25 cents/ounce is applied to powdered beverages.

Modeling Framework

An excise tax is linked to changes in body weight through changes in sugary drink price and consumption.

Logic Model for State Excise Tax

 

 

 

 

Impact of Tax on Price to Consumers

We assume 100% pass through of the tax over the 10 years. Empirical studies in Mexico and France indicate that approximately the full amount of the excise tax is passed on to consumers.18 Short-term studies for the local tax in Berkeley indicate less than complete pass through.3,19,20 The expected percent increase in sugary drink price was estimated based on an average $0.092/ounce; based on national and local price/ounce for several sugary drink categories, including ready-to-drink and powdered mixes;21-23 and inflated for higher prices in geographically remote locations in Alaska where high transportation costs increase food and beverages prices.23 The volume tax approach would result in an average 36% price increase; the graduated tax approach would result in a 34% price increase.

Sugary Drink Consumption and Price Elasticity of Demand

We used regionally-adjusted estimates of total sugary drink consumption in 2017 published in the UCONN Rudd Center Revenue Calculator for Sugar-Sweetened Beverage Taxes to adjust national age, sex, and race/ethnicity-specific consumption data from the National Health and Nutrition Examination Survey (NHANES) 2005-2010 to estimate current sugary drink consumption levels in Alaska.24 We further adjusted sugary drink consumption to account for Alaska Behavioral Risk Factor Surviellance System (BRFSS)-reported differences by race.25 A review of studies published from 2007-2012 was used to estimate how a change in the price of sugary drinks would impact consumer purchases.26 These studies found that, on average, every 10% price increase would lead to a 12% reduction in purchases.26 Recent research concerning the Berkeley tax indicates a 21% reduction in sugary drink intake among low-income populations.19

Direct effect of change in sugary drink consumption on change in weight

We conducted evidence reviews for impact of change in sugary drink intake on weight, measured by Body Mass Index (BMI), taking into account any dietary compensation.15 Four large longitudinal studies in adults27-30 of sufficient duration were identified. The relationship was modeled using a uniform distribution based on the range of the estimates of the effect of a one-serving (142 kcal) reduction on BMI (from 0.21 to 0.57). A double-blind randomized controlled trial conducted over 18 months among youth found that kids who consumed an additional daily 8 ounce serving (104 kcal) of sugary drinks gained 1 kg more weight than kids who did not.31 We assumed the same impact of change in sugary drink consumption on change in body weight for both tax structure approaches.

Reach

Since obesity can be estimated and tracked for adults and youth as young as age 2, for the purposes of the model the reach of the intervention is defined as all youth and adults ages 2 years and older in Alaska.

Costs

We assume that the two different tax structures would involve the same implementation costs. The policy change would involve start-up and ongoing labor costs for state tax department administrators. To implement the intervention, the state government would need to process tax statements and conduct audits. The state government would also incur a one-time cost to set up the new tax within the state system. Businesses would also need to prepare tax statements and participate in audits, which would require labor from private tax accountants. Cost information was drawn from states and localities with planned or implemented excise taxes on sugary drinks.15 The cost and benefit estimates do not include expected tax revenue.

CHOICES Microsimulation Model

The CHOICES microsimulation model for Alaska was used to calculate the costs and effectiveness of a volume or graduated sugary drink tax over 10 years (2015–25). This is a stochastic, discrete-time, individual-level microsimulation model designed to simulate the experience of the state population from 2015 to 2025. Cases of obesity prevented were calculated at the end of the model in 2025. The model uses data from the following sources: U.S. Census, American Community Survey, Alaska Behavioral Risk Factor Surveillance System32,33, NHANES, National Survey of Children’s Health34, the Medical Expenditure Panel Survey, and multiple national longitudinal studies. We calculated uncertainty intervals using Monte Carlo simulations programmed in Java over 1,000 iterations of the model for a population of 1,000,000 simulated individuals scaled to the state population size.15

According to this model analysis, a $0.03/ounce volume excise tax on sugary drinks in Alaska would reach all residents of the state and prevent over 1,000 cases of childhood obesity and over 7,000 cases of adult obesity in the 10th year of the model. The sugary drinks excise volume tax would also prevent 156 premature deaths due to sugary drink consumption while avoiding $43.6 million in health care costs by the final year of the model.  We project overall obesity prevalence to decline by 0.93% in the final year of the model with the tax and a decline in childhood obesity prevalence of 0.56% (the difference in the projected Alaska prevalence of obesity without the intervention and the projected Alaska prevalence of obesity in 2025 with the intervention). The sugary drink excise tax is projected to increase healthy life years and avoid $19.30 in health care costs for every $1 to implement the tax. The graduated tax is projected to result in a slightly lower impact on health and health care costs avoided and is also projected to be a cost saving approach for reducing obesity. Detailed model results are presented in the table below. A sugary drink excise tax, using either tax approach, is one of the most cost effective strategies to reduce childhood obesity the CHOICES team has modeled. 15

 

Results

Metric Volume Tax
$0.03/ounce Results
Graduated Tax
$0.03/ounce & $0.02/ounce Results

Mean

(95% Uncertainty Intervals)

Mean

(95% Uncertainty Intervals)

Effect
Cases of obesity prevented in 10th year* 7,220
(5,710; 8,080)
6,830
(5,420; 7,660)
Case of childhood obesity prevented in 10th year* 1,110
(809; 1,370)
1,030
(747; 1,270)
Reduction in obesity prevalence overall in 10th year* 0.93%
(0.74%; 1.04%)
0.88%
(0.70%; 0.99%)
Reduction in childhood obesity prevalence in 10th year* 0.56%
(0.41%; 0.70%)
0.52%
(0.38%; 0.64%)
Years with obesity prevented over 10 years 51,000
(40,700; 56,500)
48,400
(38,600; 53,600)
Life years gained over 10 years 519
(388; 635)
496
(368; 612)
Deaths prevented* over 10 years 156
(119; 185)
149
(114; 180)
Decrease in 12-ounce serving of sugary drinks per person in the first year* 134
(74.5; 230)
128
(70.4; 219)
Total decrease in gallons of sugary drinks consumed in the first year* 9,210,000 8,840,000
Cost
Health care costs avoided over 10 years^ $43.6 million
($35.4 million; $48.0 million)
$41.6 million
($33.8 million; $45.7 million)
Annual intervention cost $226,000
($192,000; $260,000)
$226,000
($192,000; 261,000)
Total 10 year intervention cost $2.25 million
($1.92 million; $2.60 million)
$2.26 million
($1.92 million; $2.61 million)
Net cost (negative means savings) over 10 yearsᵻ -$41.3 million
(-$45.9 million; -$33.0 million)
-$39.3 million
(-$43.5 million; -$31.6 million)
Health care costs avoided per $1 invested^ $19.30
($14.60; $23.80)
$18.40
($14.10; $22.70)
Reach
First year population reach* 734,000
(733,000; 734,000
734,000
(733,000; 734,000)
Cost/Effect
Cost per year with obesity prevented Costs-avoided Costs-avoided
Cost per Quality Adjusted Life Year (QALY) gained Costs-avoided Costs-avoided
Cost per case of obesity prevented Costs-avoided Costs-avoided
QALYs gained 2,090
(1,690; 2,330)
2,000
(1,620; 2,250)

All metrics reported for the population over a 10-year period and discounted at 3% per year, unless otherwise noted.

*Not discounted.

ᵻ These costs include the difference between the cost to implement the intervention and the healthcare cost savings produced over 10 years.

^does not include dental costs saved

Impact on Diabetes

 We estimated the impact of the tax-induced reduction in sugary drink intake on type 2 diabetes incidence for adults ages 18-79 years using a published meta-analysis of the relative risk of developing diabetes due to a one-serving change in sugary drink consumption35 as well as local estimates of diabetes. On average, each 8.5 ounce serving of sugary drinks per day increases the risk of diabetes by 18%. In Alaska, we estimated that a $0.03/ounce volume tax would lead to a 10% reduction in diabetes incidence — an estimated 362 cases of diabetes prevented — over a one-year period once the tax reaches its full effect; the graduated tax would lead to a similar reduction — an estimated 384 cases of diabetes prevented — over this same timeframe.

Impact on Dental Caries

We estimated the impact of a sugary drink excise tax on tooth decay cost using a longitudinal analysis of the relationship between intake of sugars and tooth decay in adults. On average, for every 10 grams higher intake of sugar per day, there is an increase in decayed, missing and filled teeth (DMFT) of approximately 0.10 over 10 years.36 As described above, we assume that the excise tax will result in a reduction in sugary drink intake. There are many studies showing a similar relationship between higher intake of sugars and tooth decay in children and youth37 and thus we assume the same relationship as found in adults.

We used the Alaska Medicaid Assistance: State Fiscal Year 2018 Fee Schedule to estimate a Medicaid cost of treating DMFT as: $692.24 for a permanent crown in children and $106.89 for a filling in both children and adults. These codes reflect treatment for one surface and do not reflect higher reimbursement rates for multi-surface treatment, temporary crowns, or potential flat tax schedules. Based on analysis of data on tooth decay, fillings and crowns for the U.S. population from NHANES 1988-1994 (the last year crowns and fillings were separately reported)39, we estimate that 78.9% of tooth decay in children and 43.5% of tooth decay in adults is treated. Using this same data set, we estimate that 97% of treatment for children is fillings and 82.5% of treatment for adults is fillings.

To estimate Medicaid-specific dental caries cost savings, we used local estimates of the numbers of people enrolled in Medicaid and the proportion receiving Medicaid dental services from  2011; these numbers may be conservative given state-wide Medicaid expansion in Alaska in fiscal year 2016. In Alaska, we estimate that a $0.03/ ounce volume tax would lead to a total savings of $11,300,000 over a period of 10 years in DMFT and of that $628,000 in Medicaid savings.  We estimate that a $0.03/ounce and $0.02/ounce graduated tax would lead to a total savings of $10,800,000 over a period of 10 years in DMFT and of that $597,000 in Medicaid savings. The Medicaid reimbursement tax estimates may underestimate the total cost savings of tooth decay treatment projected here as dental providers may charge higher amounts to patients.

Chart summarizing the Impact on Dental Caries

Expected Yearly Sugary Drink Tax Revenue1

The annual revenue from a state excise tax on sugary drinks is likely to be substantial. Based on data from the Rudd Center and CHOICES model estimates of the consumption of sugary drinks, including powdered beverages, in Alaska, a $0.03/ounce volume excise tax on ready to drink sugary drinks and $0.0025/ounce tax on powdered sugary drinks in Alaska could raise approximately $32.0 million in 2017 and a graduated excise tax ($0.03/ounce and $0.02/ounce) could raise approximately  $36.0 million in 2017.

Equity and Implementation Considerations

Concerns have been raised regarding the impact of the tax on households with low incomes. Because of the elasticity of -1.21, our analyses clearly indicate that households will spend less on sugary drinks after the tax goes into effect, providing disposable income for other purchases. We estimate that a $0.03/ounce volume tax will result in $109 million in sugary drink savings for consumers after one year and a $0.03/ounce and $0.02/ounce graduated tax will result in $105 million in sugary drink savings for consumers after one year.  In addition, we project that greater health benefits will accrue to low-income consumers who on average consume more sugary drinks than higher-income consumers; the same is true for a number of racial and ethnic groups. Racial/ethnic and income disparities in obesity outcomes should thus decrease following implementation of the modeled tax. In addition, revenue raised from a sugary drinks tax can be reinvested in low-income communities; for instance, in Berkeley, sugary drink tax revenue has been allocated for spending on school and community programs, several with a focus on low-income or minority populations, to promote healthy eating, diabetes prevention and obesity prevention.40,41

There is opposition to sugary drink excise taxes from the beverage industry, which spends over $4 billion each year nationwide on marketing.42 Public support for such taxes generally increases when the public knows the revenue is designated for health promotion activities.43 The modeled tax is likely to be sustainable if implemented based on the history of tobacco excise taxes.

Discussion

We project that the modeled sugary drink excise tax based on a volume tax structure of $0.03/ounce would prevent thousands of cases of childhood and adult obesity, prevent new cases of diabetes, increase healthy life years and avoid more in future health care costs than it costs to implement, with a lower impact for a graduated tax structure. Revenue from the tax could be used for education and health promotion efforts. Implementing the tax could also serve as a powerful health education message to reduce added sugar consumption. There is potential for a shift in social norms of sugary drink consumption based on evidence from tobacco control tax and regulatory efforts.44 There is not one reason for the obesity epidemic and there is not one solution. A sugary drink excise tax is just one of a number of cost-effective strategies that could be implemented; a multi-pronged, multi-sector approach will be necessary to reduce obesity.

 

Results prepared by the CHOICES project at the Harvard T.H. Chan School of Public Health: Gortmaker SL, Long MW, Ward ZJ, Giles CM, Barrett JL, Flax C, Resch SC, Cradock AL. Funded by The JPB Foundation and Healthy Food America. Results are those of the authors and not the funders. For further information contact cgiles@hsph.harvard.edu.  Visit www.choicesproject.org.

1Actual fee revenue may be lower than these projected estimates due to several factors. For instance, retailers may have inventories of sugary drinks obtained before a tax is implemented. There may also be some distributors/manufacturers that are non- compliant with the fee. Revenue estimations differ from the UCONN Rudd Center Revenue Calculator for Sugar-Sweetened Beverage Taxes due to the use of locally adjusted consumption estimates and the inclusion of powders taxed at a lower tax rate.

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References

  1. American Heart Association. Support for taxing sugary drinks by sugar content: Comment from Nancy Brown, American Heart Association CEO. American Heart Association website. http://newsroom.heart.org/news/support-for-taxing-sugary-drinks-by-sugar-content/. December 12, 2016. Accessed November 8, 2017
  2. Hakim D and Confessore N. Paterson seeks huge cuts and $1 billion in taxes and fees. The New York Times, Jan 19, 2010.
  3. 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. Am J Public Health. 2015 Nov;105(11):2194-201.
  4. Leonhardt D. The battle over taxing soda. The New York Times, May 19, 2010.
  5. Wang YC, Bleich SN, and Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988–2004. Pediatrics. 2008;121(6):e1604-e1614.
  6. Bleich SN, Wang YC, Wang Y and Gortmaker SL. Increasing consumption of sugar-sweetened beverages among US adults: 1988–1994 to 1999—2004. Am J Clin Nutr. 2008;89(1):372-381.
  7. Kit BK, Fakhouri TH, Park S, Nielsen SJ, Ogden CL. Trends in sugar-sweetened beverage consumption among youth and adults in the United States: 1999-2010. Am J Clin Nutr. 2013 Jul;98(1):180-8.
  8. Bleich SN, Vercammen KA, Koma JW, Li Z. Trends in Beverage Consumption Among Children an Adults, 2003-2014. Obesity (Silver Spring). 2018 Feb;26(2):432-441. doi: 10.1002/oby.22056. Epub 2017 Nov 14.
  9. Malik VS, Pan A, Willett WC , Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98(4):1084-1102.
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  11. S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/.
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  13. Brownell KD, Farley T, Willett WV, et al. The public health and economic benefits of taxing sugar-sweetened beverages. New Engl J Med. 2009;361(16):1599-1605.
  14. 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.
  15. Gortmaker SL, Wang YC, 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 (Millwood). 2015 Nov 1;34(11):1932-9.
  16. Institute of Medicine. Local Government Actions to Prevent Childhood Obesity, 2009. National Academies Press: Washington, DC.
  17. Francis N, Marron, D, Rueben, K. The Pros and Cons of Taxing Swettened Beverages Based on Sugar Content.Urban Instittue, 2016. Washington, DC.
  18. Colchero MA, Salgado JC, Unar-Munguía M, Molina M, Ng S, Rivera-Dommarco JA. Changes in Prices After an Excise Tax to Sweetened Sugar Beverages Was Implemented in Mexico: Evidence from Urban Areas. PLoS ONE. 2015;10(12): e0144408.
  19. Falbe J, Thompson HR, Becker CM, Rojas N, McCulloch CE, Madsen KA. Impact of the Berkeley Excise Tax on Sugar-Sweetened Beverage Consumption. Am J Public Health. 2016 Aug 23:e1-e7.
  20. Ng SW, Silver L, Ryan-Ibarra S, Induni M, Hamma C, Poti J , Popkin B. Berkeley Evaluation of Soda Tax (BEST) Study Preliminary Findings. Presentation at the annual meeting of the American Public Health Association, Chicago, IL, November
  21. Powell LM, Isgor z, Rimkus L, Chaloupka FJ. Sugar-sweetened beverage prices: Estimates from a national sample of food outlets. Chicago, IL: Bridging the Gap Program, Health Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago, 2014. Available at: http://www.bridgingthegapresearch.org/_asset/ww9rpz/btg_SSB_price_brief_FINAL_Jan_2014.pdf.
  22. Luick, B. Personal Communications about results from December 2016 Alaska Food Cost Survey.
  23. Potempa AE, Beverage Costs in Alaska: Select Communities, March 2017. Unpublished data.
  24. UCONN Rudd Center. Revenue Calculator for Sugar-Sweetened Beverage Taxes. Jan 2014. Accessed March 2016, http://www.uconnruddcenter.org/revenue-calculator-for-sugar-sweetened-beverage-taxes.
  25. Sugary Drink Prevalence. Retrieved on Jan 9, 2017, from Alaska Department of Health and Social Services, Indicator-Based Information System for Public Health (AK-IBIS) website: http://ibis.dhss.alaska.gov/.
  26. Powell LM, Chriqui JF, Khan T, Wada R, Chaloupka FJ. Assessing the potential effectiveness of food and beverage taxes and subsidies for improving public health: a systematic review of prices, demand and body weight outcomes. Obes Rev. 2013;14(2): p. 110-28.
  27. Chen L. Reduction in consumption of sugar-sweetened beverages is associated with weight loss: the PREMIER trial. Am J Clin Nutr. 2009;89(5):1299-306.
  28. Mozaffarian D, Hao T, Rimm ER, Willett WC, Hu FB. Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med. 2011;364(25): p. 2392-404.
  29. Palmer JR, Boggs DA, Krishnan S, Hu FB, Singer M, Rosenberg L. Sugar-sweetened beverages and incidence of type 2 diabetes mellitus in African American women. Arch Intern Med. 2008;168(14): p. 1487-92.
  30. Schulze MB, Mason JE, Ludwig D, et al. Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. JAMA. 2004;292(8): p. 927-34.
  31. de Ruyter JC, Olthof MR, Seidell JC, Katan MB. A trial of sugar-free or sugar-sweetened beverages and body weight in Children. N Engl Med. 2012;367(15):1397-1406.
  32. Obesity prevalence. Retrieved on Jan 9, 2017, from Alaska Department of Health and Social Services, Indicator-Based Information System for Public Health (AK-IBIS) website: http://ibis.dhss.alaska.gov/.
  33. 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.
  34. 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). 2016 Aug 30.
  35. Imamura F, O’Connor L, Ye Z, Mursu J, Hayashino Y, Bhupathiraju SN, Forouhi NG. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes. Br J Sports Med. 2016 Apr;50(8):496-504.
  36. Bernabé E, Vehkalahti MM, Sheiham A, Lundqvist A, Suominen AL. The Shape of the Dose-Response Relationship between Sugars and Caries in Adults. J Dent Res. 2016 Feb;95(2):167-72.)
  37. Sheiham A, James WP. 2014. A new understanding of the relationship between sugars, dental caries and fluoride use: implications for limits on sugars consumption. Public Health Nutr. 17(10):2176–2184.
  38. Alaska Medicaid Health Enterprise. Alaska Medicaid Assistance: State Fiscal Year 2018 Fee Schedule. 2018. Avaliable from: http://manuals.medicaidalaska.com/docs/dnld/Fees_Dental_SFY2018.pdf
  39. Ward Z, et al. NHANES III Dental Examination: An Incisive Report. unpublished report; 2018.
  40. Lynn J. (2016, Jan 20). City council votes to allocate ‘soda tax’ revenue to school district, city organizations. The Daily Californian. Retrieved from http://www.dailycal.org/2016/01/20/city-council-votes-allocate-soda-tax-revenue-school-district-city-organizations/.
  41. Berkeley City Council. (2016, June 14). Berkeley City Council meeting. [Annotated Agenda]. Retrieved from https://www.cityofberkeley.info/Clerk/City_Council/2016/06_June/City_Council__06-14-2016_-_Meeting_Info.aspx.
  42. Federal Trade Commission. A review of food marketing to children and adolescents: follow-up report. Washington, DC: FTC; 2012Dec. Available from: http://www.ftc.gov/os/2012/12/121221foodmarketingreport.pdf.
  43. Friedman R. Public Opinion Data, 2013: New Haven, CT: Yale Rudd Center for Food Policy & Obesity.
  44. Frieden TR, Mostashari F, Kerker BD, Miller N, Hajat A, Frankel M. Adult tobacco use levels after intensive tobacco control measures: New York City, 2002-2003. Am J Public Health. 2005;95(6):1016-1023.

 

Brief: Alaska Sugary Drinks Tax (A State Excise Tax)

The information in this brief is intended for educational use only.

This brief provides a summary of the CHOICES Learning Collaborative Partnership simulation model of a $0.03-per-ounce state volume excise tax on sugary drinks. The tax, which would be administered by the state, aims to reduce consumption of sugary drinks.

The Issue

Although sugary drinks consumption has declined in recent years, adolescents and young adults in the United States consume more sugary drinks than the Dietary Guidelines for Americans, 2015-2020 recommend, with persistent racial/ethnic disparities.1-4 Research has linked sugary drink consumption to excess weight gain, diabetes, and heart disease. Sugary drink consumption may increase the risk of developing chronic diseases through effects on body weight and other mechanisms.5-6 The Dietary Guidelines for Americans, 2015-20207 recommend reducing sugary drink intake to support a healthy body weight. Drawing upon the success of tobacco taxation and decades of economic research, public health experts have studied taxes on unhealthy foods and beverages.8-11 In 2009, the Institute of Medicine recommended that local governments implement tax strategies to reduce consumption of “calorie-dense, nutrient-poor foods,” emphasizing sugary drinks as an appropriate target for taxation.12

About the Potential Impact of a Sugary Drink Excise Tax

The modeled sugary drinks excise tax would apply at the wholesale level (that is, to local bottlers, distributors and/or manufacturers) and be passed on directly to consumers in full as part of the price of the product. The tax would apply to all beverages with added caloric sweeteners but not to 100 percent juices, milk products, or artificially sweetened beverages. The $0.03-per-ounce excise tax would increase sugary drink prices on average in Alaska by 36.5 percent. Implementation costs of the tax to state government would include a one-time capital cost to build the system to assess and collect the tax and annual administrative cost associated with assessing, processing and collecting tax statements. The implementation costs to the private sector include the cost for efforts from businesses to prepare tax payments and statements and the cost of time required for state audits using private tax accountants. The tax is projected to avoid $19.40 in obesity-related health care costs for every $1 it would cost to implement.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of the sugary drinks excise tax over 10 years with costs and outcomes associated with not implementing the tax.

Implementing the $0.03/oz sugary drink excise tax in Alaska is an investment in the future. The tax would result in:
If a $0.03 per ounce excise tax in Alaska went into effect, then 7,220 cases of childhood and adult obesity would be prevented in year 10, the final year of the model. Over 10 years, 156 deaths would be prevented. Reducing sugary drink intake by 134 servings per Alaskan, on average, in the first year (1 serving equals 12 ounces). $43.6 million in health care costs would be avoided over 10 years.

Conclusions and Implications

According to this model analysis, a $0.03-per-ounce tax on sugary drinks in Alaska would reach all residents of the state and prevent 1,110 cases of childhood obesity and 6,110 cases of adult obesity in year 10. The sugary drinks excise tax would also prevent 156 premature obesity-related deaths and $43.6 million in health care costs would be avoided over 10 years.

There are concerns about the impact of the tax on low-income households. This analysis indicates that households would spend less on sugary drinks after the tax takes effect, increasing disposable income for other purchases. On average, low-income households consume more sugary drinks than higher-income households. Low-income households will spend less on sugary drinks and consume fewer of these drinks after the tax takes effect, which would lead to greater health benefits. The same is true for certain racial and ethnic groups. Thus, racial/ethnic disparities in obesity outcomes should decline following implementation of the proposed tax. In addition, revenue from the sugary drink tax could be reinvested in low-income communities. Implementing the tax in Alaska could send a powerful message to reduce added sugar consumption.

References

  1. Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988–2004. Pediatrics. 2008;121(6):e1604-e1614.
  2. Nielsen SJ and Popkin BM. Changes in beverage intake between 1977 and 2001. Am J Prev Med. 2004; 27(3):205-210.
  3. Bleich, SN, Wang YC, Wang Y, Gortmaker, SL. Increasing consumption of sugar-sweetened beverages among US adults: 1988—1994 to 1999—2004. Am J Clin Nutr. 2008; 26883.
  4. Bleich, SN, Vercammen KA, Koma, JW, Li Z. Trends in beverage consumption among children and adults, 2003-2014. Obesity. 2017; doi: 10.1002/oby.22056.
  5. Malik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98(4):1084-1102.
  6. Chen L, Caballero B, Mitchel DC, Loria C, et al. Reducing consumption of sugar-sweetened beverages is associated with reduced blood pressure: A prospective study among United States adults. Circulation. 2010;121(22):2398-2406.
  7. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines
  8. Chaloupka FJ, Powell LM, Chriqui JF. Sugar-sweetened beverage taxes and public health: A Research Brief. Minneapolis, MN: Robert Wood Johnson Foundation, Healthy Eating Research, 2009.
  9. Brownell KD, Farley T, Willett WV, et al. The public health and economic benefits of taxing sugar-sweetened beverages. New Engl J Med. 2009;361(16):1599-1605.
  10. 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.
  11. Gortmaker SL, Wang YC, 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 (Millwood). 2015 Nov 1;34(11):1932-9.
  12. Institute of Medicine. Local Government Actions to Prevent Childhood Obesity, 2009. National Academies Press: Washington, DC.
Suggested Citation:

Gortmaker S, Long M, Barrett J, Cradock A, Flax C, Giles C, Ward Z. Alaska Sugary Drink Tax: A State Excise Tax {Issue Brief}. The CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; July, 2018.

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

This brief was developed through the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health. This brief is intended for educational use only. Funded by The JPB Foundation. Results are those of the authors and not the funders.

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Brief: Cost-Effectiveness of a Sugar-Sweetened Beverage Tax in New Hampshire

The information in this brief is intended to provide educational information on the cost-effectiveness of SSB taxes.

Intervention Strategy Description

Implementation of a state excise tax of either $0.02/ounce or $0.01/ounce of sugar-sweetened beverages (SSBs), administered by the New Hampshire Department of Revenue Administration (DORA) and based on proposals considered by federal, state, and local governments.1‐4

Background 

Summary Results of Sugar-Sweetened Beverage Excise Tax in New HampshireSSBs include all beverages with added caloric sweeteners. The modeled excise tax does not apply to 100% juice, milk products, or artificially-sweetened beverages. Although sugary drinks consumption has declined in recent years, adolescents and young adults in the United States consume more sugary drinks than the Dietary Guidelines for Americans recommends, with persistent racial/ethnic disparities.5-8 Randomized trials and longitudinal studies have linked SSB consumption to excess weight gain, diabetes, and cardiovascular disease. Consumption of SSBs increases the risk of chronic diseases through its impact on BMI and other mechanisms.9,10 The Dietary Guidelines for Americans, 201511 recommends that individuals reduce SSB intake in order to manage their body weight. Drawing on the success of tobacco taxation and decades of economic research, public health experts have called for higher taxes on SSBs and documented their likely impact.12-15 In 2009, the IOM recommended that local governments implement tax strategies to reduce consumption of “calorie-dense, nutrient-poor foods,” emphasizing SSBs as an apt target for taxation.16

Modeling Framework

Increased state excise tax linked to change in BMI through change in SSB price and consumption.

Logic Model for Sugar Sweetened Beverage Tax

 

 

 

 

Impact of Tax on Price to Consumers

We assume 100% pass through of the tax over the ten years. Empirical studies in Mexico and France indicate that approximately the full amount of the excise tax is passed on to consumers.17 Short term studies for the local tax in Berkeley indicate less than complete pass-through.3,18,19 The expected percent increase in SSB price was estimated based on the average $0.059/ounce reported in a review of beverage demand elasticity (inflated to $0.0612 in 2014 dollars).20 The price per ounce in this study was based on a weighted average across stores, restaurants and other sources proportional to the source of consumed SSBs in NHANES 2009-2010. The price per ounce of SSBs purchased in stores was calculated using weighted averages of two-liter bottles, 12-can cases, and single-serve bottles or cans based on the distribution of package sizes estimated from 2010 Nielsen Homescan data. The $0.02/ounce increased excise tax would result in a 32.7% price increase; the $0.01/ounce increased excise tax in a 16.3% price increase. We assumed that the tax rate would be adjusted annually for inflation to maintain the 32.7% or 16.3% price increase throughout the ten-year modeling time frame.

SSB Consumption and Price Elasticity of Demand

We used regionally-adjusted estimates of total SSB consumption in 2015 published in the UCONN Rudd Center Revenue Calculator for Sugar-Sweetened Beverage Taxes to adjust national age, sex, and race/ethnicity-specific consumption data from NHANES 2005-2010 to estimate current SSB consumption levels in New Hampshire.21 Powell et al reviewed studies published 2007-2012 and estimated a mean own-price elasticity of demand for SSBs weighted by SSB category consumption shares of -1.21, ranging from -3.87 to -0.69.22 Recent research concerning the Berkeley tax indicates a 21% reduction in SSB intake among low income populations.18

Direct effect of change in SSB consumption on change in BMI

We conducted evidence reviews for impact of change in SSB intake on BMI, taking into account any dietary compensation.15 Four large longitudinal studies in adults23-26 of sufficient duration were identified. The relationship was modeled using a uniform distribution based on the range of the estimates of the effect of a one serving reduction on BMI (from 0.21 to 0.57). Among youth, a double-blind randomized controlled trial conducted over 18 months found that an additional 8 oz serving of SSBs led to a 1 kg greater weight gain.27

Reach

The intervention reaches all youth and adults ages 2 years and older in New Hampshire.

Costs

The policy change will involve start up and ongoing labor costs for state tax department administrators. To implement the intervention, the state government will need to process tax statements and conduct audits. Businesses will also need to prepare tax statements and participate in audits, which will require labor from private tax accountants. Cost information was drawn states and localities with planned or implemented excise taxes on sugary drinks.15 The cost and benefit estimates do not include expected tax revenue.

CHOICES Microsimulation Model

The CHOICES microsimulation model for New Hampshire was used to calculate the costs and effectiveness over ten years (2015–25). This is a stochastic, discrete-time, individual-level microsimulation model designed to simulate the experience of the state population from 2015 to 2025. Cases of obesity prevented were calculated at the end of the model in 2025. The model uses data from: US Census, American Community Survey, Behavioral Risk Factor Surveillance System28, NHANES, National Survey of Children’s Health29, the Medical Expenditure Panel Survey, and multiple national longitudinal studies.30 We calculated uncertainty intervals using Monte Carlo simulations programmed in Java over one thousand iterations of the model for a population of one million simulated individuals for a population of one million simulated individuals scaled to the state population size.15

 

Results

Metric $0.02/ounce Results $0.01/ounce Results
Cost/Effect
Cost per Year with Obesity Prevented Cost-saving Cost-saving
Cost per Quality Adjusted Life Year (QALY) Gained Cost-saving Cost-saving
Cost per Case of Obesity Prevented Cost-saving Cost-saving
QALYs Gained 5,670 (1,770; 14,500) 2,880 (874; 7,500)
Reach
First Year Population Reach* 1,310,000 1,310,000
Effect
Decrease in 12-oz Servings of SSBs per Person in the First Year* 158 (92.2; 317) 78.6 (45.8; 157)
Cases of Obesity Prevented* 17,400 (5,560; 44,000) 8,880 (2,770; 22,900)
Years with Obesity Prevented 124,000 (39,700; 313,000) 63,500 (19,800; 163,000)
Life Years Gained 1,580 (480; 3,880) 808 (233; 2,170)
Deaths Averted* 464 (143; 1,160) 238 (68; 601)
Cost
Annual Intervention Cost $686,000 $686,000
Net Cost (negative means savings) -$129mill (-$342mill; -$35.1mill) -$61.7mill (-$171mill; -$14.3mill)
Health Care Cost Savings per $1 Invested $19.80 ($6.12; $50.80) $10.00 ($3.09; $26.00)

All metrics reported for the population over a 10-year period and discounted at 3% per year, unless otherwise noted.

*Not discounted.

ᵻ These costs include the difference between the cost to implement the intervention and the healthcare cost savings produced over 10 years.

Impact on Diabetes

We estimated the impact of the tax-induced reduction in SSB intake on diabetes incidence for adults ages 18-79 years using a published meta-analysis of the relative risk of developing diabetes due to a one-serving change in SSB consumption31 as well as local estimates of diabetes. On average, each 8.5 oz serving of SSBs per day increases the risk of diabetes by 18%. In New Hampshire, we estimated that the $0.02/ounce SSB increased excise tax would lead to a reduction in diabetes incidence- an estimated 817 cases of diabetes prevented- over a one-year period once the tax reaches its full effect; the $0.01/ounce SSB increased excise tax would lead to an estimated 423 cases of diabetes prevented.

Impact on Tooth Decay

We estimated the impact of a sugar sweetened beverage (SSB) excise tax on tooth decay cost for the state using a longitudinal analysis of the relationship between intake of sugars and tooth decay in adults. On average, for every 10 grams higher intake of sugar per day, there is an increase in DMFT of approximately 0.10 over 10 years.32 As described above, we assume that the excise tax will result in a reduction in SSB intake. There are many studies showing a similar relationship between higher intake of sugars and tooth decay in children and youth33 and thus we assume the same relationship as found in adults. We used 2018 New Hampshire Medicaid Management Information System (NH MMIS) procedure code data to estimate the average Medicaid cost of treating decayed, missing and filled teeth (DMFT): $173 for a permanent crown and $89 for a filling.34 These codes reflect treatment for one surface and do not reflect higher reimbursement rates for multi-surface treatment, temporary crowns, or potential flat fee schedules. Based on analysis of data on tooth decay, fillings and crowns for the U.S. population from NHANES 1988-1994 (the last year crowns and fillings were separately reported) (personal communication Zachary Ward, April 2018)35, we estimate that 78.9% of tooth decay in children and 43.5% of tooth decay in adults is treated. Using this same data set, we estimate that 97% of treatment for children is fillings and 82.5% of treatment for adults is fillings. To estimate Medicaid-specific dental caries cost savings, we used local estimates of the numbers of people enrolled in Medicaid and the proportion receiving Medicaid dental services. Because of limited Medicaid dental coverage for adults in New Hampshire, only children are included in the Medicaid-specific calculations. In New Hampshire, we estimated that the $0.02/ounce tax over a period of 10 years would lead to a total saving in DMFT of $3.62 million and $695,000 in Medicaid savings. The $0.01/ounce tax would lead to a total over a period of 10 years in DMFT savings of $1.33 million and $255,000 in Medicaid savings. The Medicaid reimbursement fee estimates may underestimate the total cost savings of tooth decay treatment projected here as dental providers may charge higher amounts to patients.

Expected Yearly SSB Tax Revenue

The annual revenue from a city excise tax on sugary beverages is likely to be substantial. According to the Rudd Center Revenue Calculator for Sugar Sweetened Beverage,21 a $0.02/ounce excise tax in New Hampshire could raise as much as $78 million and a $0.01/ounce excise tax as much as $54 million in 2017. Actual tax revenue may be lower than these projected estimates due to several factors. The Rudd Center Revenue estimates are based on regional sales data adjusted for state or city specific demographics36; sales data for specific states and/or cities within those regions may vary from the regional average. Retailers may have inventories of sugary drinks obtained before the tax was implemented. Residents living close to city, county and/or state borders may also purchase sugary drinks in neighboring communities without such a tax. Finally, there may be some distributors/manufacturers that are non-compliant with the tax. The Rudd Center notes that their revenue projections “should be considered optimistic…and adjusted downward by 10-30%.”21

Equity and Implementation Considerations

Concerns have been raised regarding the impact of the tax on households with low incomes. Because of the elasticity of -1.21, our analyses clearly indicate that households will spend less on SSBs after the tax goes into effect, providing disposable income for other purchases. In addition, we project that greater health benefits will accrue to low-income consumers who on average consume more SSBs than higher income consumers; the same is true for a number of racial and ethnic groups. Disparities in obesity outcomes should thus decrease following implementation of the proposed tax. In addition, revenue raised from an SSB tax can be reinvested in low income communities; for instance, in Berkeley, CA SSB tax revenue has been allocated for spending on school and community programs, several with a focus on low income or minority populations, to promote healthy eating, diabetes and obesity prevention.37,38

There is opposition from the beverage industry, which spends over $4 billion/year nationwide on marketing.39 Public support for such taxes generally increases with earmarking for prevention activities.40 Relatively small beverage excise taxes are currently applied across many states. The proposed tax is likely to be sustainable if implemented based on the history of tobacco excise taxes. There is potential for a shift in social norms of SSB consumption based on evidence from tobacco control tax and regulatory efforts.41

Discussion

We project that the proposed SSB excise tax policy of $0.02/ounce will prevent thousands of cases of childhood and adult obesity, prevent new cases of diabetes, increase healthy life years and save more in future health care costs than it costs to implement, with a lower impact for an increase of $0.01/ounce tax. Revenue from the tax can be used for education and health promotion efforts. Implementing the tax could also serve as a powerful social signal to reduce sugar consumption.

 

Results prepared by the CHOICES Project at the Harvard T.H. Chan School of Public Health: Gortmaker SL, Long MW, Ward ZJ, Giles CM, Barrett JL, Resch SC, Cradock AL and the New Hampshire Division of Public Health Services, Department of Health and Human Services: Foster SJ and Hammond WC. Funded by The JPB Foundation. Results are those of the authors and not the funders. For further information: contact cgiles@hsph.harvard.edu.

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References

  1. American Public Health Association. Taxes on Sugar-Sweetened Beverages. 2012.
  2. Hakim D and Confessore N. Paterson seeks huge cuts and $1 billion in taxes and fees. The New York Times, Jan 19, 2010.
  3. 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. Am J Public Health. 2015 Nov;105(11):2194-201.
  4. Leonhardt D. The battle over taxing soda. The New York Times, May 19, 2010.
  5. Wang YC, Bleich SN, and Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988–2004. Pediatrics. 2008;121(6):e1604-e1614.
  6. Bleich SN, Wang YC, Wang Y and Gortmaker SL. Increasing consumption of sugar-sweetened beverages among US adults: 1988–1994 to 1999—2004. Am J Clin Nutr. 2008;89(1):372-381.
  7. Kit BK, Fakhouri TH, Park S, Nielsen SJ, Ogden CL. Trends in sugar-sweetened beverage consumption among youth and adults in the United States: 1999-2010. Am J Clin Nutr. 2013 Jul;98(1):180-8.
  8. Bleich SN, Vercammen KA, Koma JW, Li Z. Trends in Beverage Consumption Among Children an Adults, 2003-2014. Obesity (Silver Spring). 2018 Feb;26(2):432-441. doi: 10.1002/oby.22056. Epub 2017 Nov 14.
  9. Malik VS, Pan A, Willett WC , Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98(4):1084-1102.
  10. Chen L, Caballero B, Mitchell DC, et al. Reducing consumption of sugar-sweetened beverages is associated with reduced blood pressure a prospective study among United States adults. Circulation. 2010;121(22):2398-2406.
  11. S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/.
  12. Chaloupka FJ, Powell LM, and Chriqui JF. Sugar-sweetened beverage taxes and public health: A Research Brief. Minneapolis, MN: Robert Wood Johnson Foundation, Healthy Eating Research, 2009.
  13. Brownell KD, Farley T, Willett WV, et al. The public health and economic benefits of taxing sugar-sweetened beverages. New Engl J Med. 2009;361(16):1599-1605.
  14. 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.
  15. Gortmaker SL, Wang YC, 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 (Millwood). 2015 Nov 1;34(11):1932-9.
  16. Institute of Medicine. Local Government Actions to Prevent Childhood Obesity, 2009. National Academies Press: Washington, DC.
  17. Colchero MA, Salgado JC, Unar-Munguía M, Molina M, Ng S, Rivera-Dommarco JA. Changes in Prices After an Excise Tax to Sweetened Sugar Beverages Was Implemented in Mexico: Evidence from Urban Areas. PLoS ONE. 2015;10(12): e0144408.
  18. Falbe J, Thompson HR, Becker CM, Rojas N, McCulloch CE, Madsen KA. Impact of the Berkeley Excise Tax on Sugar-Sweetened Beverage Consumption. Am J Public Health. 2016 Aug 23:e1-e7.
  19. Ng SW, Silver L, Ryan-Ibarra S, Induni M, Hamma C, Poti J , Popkin B. Berkeley Evaluation of Soda Tax (BEST) Study Preliminary Findings. Presentation at the annual meeting of the American Public Health Association, Chicago, IL, November
  20. Powell LM, Isgor z, Rimkus L, Chaloupka FJ. Sugar-sweetened beverage prices: Estimates from a national sample of food outlets. Chicago, IL: Bridging the Gap Program, Health Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago, 2014. Available at: http://www.bridgingthegapresearch.org/_asset/ww9rpz/btg_SSB_price_brief_FINAL_Jan_2014.pdf.
  21. UCONN Rudd Center. Revenue Calculator for Sugar-Sweetened Beverage Taxes. Jan 2014. Accessed March 2016, http://www.uconnruddcenter.org/revenue-calculator-for-sugar-sweetened-beverage-taxes.
  22. Powell LM, Chriqui JF, Khan T, Wada R, Chaloupka FJ. Assessing the potential effectiveness of food and beverage taxes and subsidies for improving public health: a systematic review of prices, demand and body weight outcomes. Obes Rev. 2013;14(2): p. 110-28.
  23. Chen L. Reduction in consumption of sugar-sweetened beverages is associated with weight loss: the PREMIER trial. Am J Clin Nutr. 2009;89(5):1299-306.
  24. Mozaffarian D, Hao T, Rimm ER, Willett WC, Hu FB. Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med. 2011;364(25): p. 2392-404.
  25. Palmer JR, Boggs DA, Krishnan S, Hu FB, Singer M, Rosenberg L. Sugar-sweetened beverages and incidence of type 2 diabetes mellitus in African American women. Arch Intern Med. 2008;168(14): p. 1487-92.
  26. Schulze MB, Mason JE, Ludwig D, et al. Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. JAMA. 2004;292(8): p. 927-34.
  27. de Ruyter JC, Olthof MR, Seidell JC, Katan MB. A trial of sugar-free or sugar-sweetened beverages and body weight in Children. N Engl Med. 2012;367(15):1397-1406.
  28. 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.
  29. 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). 2016 Aug 30.
  30. Ward Z, Long M, Resch S, Giles C, Cradock A, Gortmaker S. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. N Engl J Med. 2017 Nov 30;377(22):2145-2153.
  31. Imamura F, O’Connor L, Ye Z, Mursu J, Hayashino Y, Bhupathiraju SN, Forouhi NG. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes. Br J Sports Med. 2016 Apr;50(8):496-504.
  32. Bernabé E, Vehkalahti MM, Sheiham A, Lundqvist A, Suominen AL. The Shape of the Dose-Response Relationship between Sugars and Caries in Adults. J Dent Res. 2016 Feb;95(2):167-72.)
  33. Sheiham A, James WP. 2014. A new understanding of the relationship between sugars, dental caries and fluoride use: implications for limits on sugars consumption. Public Health Nutr. 17(10):2176–2184.
  34. NH MMIS Health Enterprise Portal . Procedure Code Listing Dental Services 2012. Updated March 3, 2018. https://nhmmis.nh.gov/portals/wps/wcm/connect/89433b0044ecdd40841dd700fe2877ea/2018+NH+Fee+Schedule+Covered+Procedures+03232018.pdf?MOD=AJPERES
  35. Ward, Z. et al . NHANES III Dental Examination: An Incisive Report. Unpublished report. 2018
  36. UCONN Rudd Center. Data and Assumptions. March 2017. Accessed April 2018. http://www.uconnruddcenter.org/files/Pdfs/Calculator%20Data_Methods_71917.pdf
  37. Lynn J. (2016, Jan 20). City council votes to allocate ‘soda tax’ revenue to school district, city organizations. The Daily Californian. Retrieved from http://www.dailycal.org/2016/01/20/city-council-votes-allocate-soda-tax-revenue-school-district-city-organizations/.
  38. Berkeley City Council. (2016, June 14). Berkeley City Council meeting. [Annotated Agenda]. Retrieved from https://www.cityofberkeley.info/Clerk/City_Council/2016/06_June/City_Council__06-14-2016_-_Meeting_Info.aspx.
  39. Federal Trade Commission. Marketing Food to Children and Adolescents: A Review of Industry Expenditures, Activities, and Self-Regulation —A Report to Congress. Washington, DC: Federal Trade Commission, Bureau of Consumer Protection and Bureau of Economics, 2008. https://www.ftc.gov/sites/default/files/documents/reports/marketing-food-children-and-adolescents-review-industry-expenditures-activities-and-self-regulation/p064504foodmktingreport.pdf
  40. Friedman R. Public Opinion Data, 2013: New Haven, CT: Yale Rudd Center for Food Policy & Obesity.
  41. Frieden TR, Mostashari F, Kerker BD, Miller N, Hajat A, Frankel M. Adult tobacco use levels after intensive tobacco control measures: New York City, 2002-2003. Am J Public Health. 2005;95(6):1016-1023.

 

Brief: Childcare Policies Can Build a Healthier Future in Philadelphia

The information in this brief is intended for educational use only.

In June 2017, Philadelphia’s Board of Health passed a resolution recommending that ECE (early childhood education) providers limit screen time and sweet drinks, including juice, for the children in their care.1

If all Philadelphia ECE providers implemented these voluntary recommendations, hundreds of children would see improved health outcomes, and $2.82 million could be saved over the next 10 years.

Analysis

The Philadelphia Department of Public Health (PDPH) collaborated with a team of researchers at the Harvard T.H. Chan School of Public Health2 to perform a cost-effectiveness analysis of policies to limit screen time and eliminate sweet drinks in early childhood settings. A cost-effectiveness analysis compares the health impact and health care cost savings resulting from implementing an initiative with maintaining the status quo. The analysis predicts how much would be spent or saved by implementing a policy or program.

PDPH and the Harvard Chan School called on local and national data and the expertise of partners3 to project costs and outcomes specific to Philadelphia’s ECE landscape. Projected costs, including training and technical assistance for ECE providers, would total $638,000 over 10 years. Projected savings, primarily from serving water instead of sweet drinks, would be $3.28 million.4 Over the same 10 year period, these changes would reach 114,000 children and prevent 279 cases of childhood obesity.

ECE Provider Savings

There are 1,661 licensed ECE providers in Philadelphia. Based on data PDPH collected from a sample of these providers, the Harvard researchers estimated the current frequency of serving sugary drinks and 100% juice in Philadelphia child care programs, average serving sizes, and average ounces served per day. They then multiplied the average ounces served per day by the price per ounce of each drink (from the USDA’s CNPP food price database). Finally, they adjusted for the fact that, since 100% juice can be reimbursed as “fruit” for the Child and Adult Care Food Program (CACFP), programs that participate in CACFP would incur costs to replace juice with whole fruit at breakfast or lunch and whole grains at snack; this analysis assumes that programs that do not participate in CACFP make the same substitutions.

These calculations yielded an average cost saving per child per day of about $0.013 for eliminating sugary drinks and $0.05 per child per day for eliminating 100% juice (that’s about $674 saved per year for the average center).

Many ECE providers in Philadelphia (including nearly 84% of centers) have already eliminated sugary drinks. Some (including nearly 18% of centers) have already eliminated 100% juice.4 Even so, if all licensed ECE providers in Philadelphia eliminated sugary drinks and 100% juice entirely, they (and their food vendors and CACFP sponsors) would save $3.28 million over 10 years. If centers that do not participate in CACFP replaced that juice with free water, these savings would increase to $4.89 million over 10 years.

If this policy were implemented, then 114,00 children would be reached over 10 years, $2.82 million in net costs would be saved, and, on average, $674 would be saved per program.

Conclusions and Implications

Every child deserves a healthy start in life. Alarmingly, an estimated 33% of children born in 2000 and up to 50% of African American and Hispanic children will develop diabetes in their lifetimes.5 For many of these children, good nutrition (including fewer sweet drinks and less exposure to unhealthy food and beverage marketing online and on TV) can prevent or delay diabetes and other chronic conditions that are the leading causes of death and disability in our city.

Philadelphia’s licensed ECE providers serve around 40,000 children ages 2-5 each year. The Board of Health recommendations aim to support more providers in making small changes that will support healthier environments for all of these children and set them up for long, healthy lives.

The results of this cost-effectiveness analysis demonstrate the fiscal sense of the Board of Health’s recommendations to limit screen time and eliminate sweet drinks, including juice. The results reinforce the importance of investing in prevention efforts. Shortchanging prevention efforts can lead to more costly and complicated treatment options in the future, whereas teaching small changes to young children can help them develop healthy habits for life.

References

  1. City of Philadelphia Department of Public Health, Board of Health, Resolution on Childhood Obesity Prevention in Early Childhood Care, Approved June 8, 2017; http://www.phila.gov/health/pdfs/boardofhealth/Board%20of%20Health%20ECE%20Resolution%20Approved%20June%208%202017.pdf
    The full recommendations state:
    No sweetened drinks in early childhood settings
    No fruit juice (including 100% juice) in early childhood settings
    Water should be available, easily accessible to children throughout the day and offered with meals
    Screen time for children aged 2 years and older limited to 30 minutes per week
    No screen time for children under age 2 in early childhood settings
  2. The Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) at the Harvard T.H. Chan School of Public Health is working to help reverse the US obesity epidemic by identifying the most cost-effective childhood obesity interventions.
  3. Thank you especially to the Delaware Valley Association of Young Children, Mayor’s Office of Education, Public Health Management Corporation, and School District of Philadelphia.
  4. Full calculations are available from PDPH; contact Shannon Dryden at Shannon.Dryden@Phila.gov.
  5. Gregg EW et al Trends in lifetime risk and years of life lost due to diabetes in the USA, 1985-2011: a modeling study. The Lancet Diabetes and Endocrinology 2(11) 867-874 downloaded from: http://www.thelancet.com/action/showFullTextImages?pii=S2213-8587%2814%2970161-5
Suggested Citation:

Pharis M, Lawman H, Root M, Dryden S, Wagner A, Bettigole C, Mozaffarian, RS, Kenney EL, Cradock AL, Gortmaker SL, Giles CM, Ward ZJ. Philadelphia, PA: Childcare Policies Can Build a Better Future {Issue Brief}. Philadelphia Department of Public Health, Philadelphia, PA, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; December 2017. 

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

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the Philadelphia Department of Public Health through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. Funded by The JPB Foundation. Results are those of the authors and not the funders.

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Brief: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) Intervention in Oklahoma

The information in this brief is intended for educational use only.

This brief summarizes the CHOICES Learning Collaborative Partnership simulation model of the impact of integrating the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) program into Oklahoma’s Reaching for the Stars Quality Rating and Improvement System. Child care programs achieving Level 2 or higher would complete NAP SACC.

The Issue

Over the past three decades, more and more people have developed obesity.1 Today, nearly nine percent of 2-5 year olds have obesity.2 Now labeled as an epidemic, health care costs for treating obesity-related health conditions such as heart disease and diabetes were $147 billion in 2008.3 While multiple strategies are needed to reverse the epidemic, emerging prevention strategies directed at children show great promise.4 A large body of evidence shows that healthy eating, physical activity, and limited time watching TV helps kids grow up at a healthy weight.

In Oklahoma, 41% of 2-5 year olds attend a licensed child care center or family child care home, and most of them attend a program involved in Reaching for the Stars.5 Child care programs can offer healthy, nurturing environments for children; Reaching for the Stars can encourage and empower programs to voluntarily improve nutrition, physical activity, and screen time standards.

About NAP SACC and Reaching for the Stars

NAP SACC is an evidence-based, trusted intervention for helping child care programs improve their practices regarding nutrition, active play, and screen time and has demonstrated impacts on reducing childhood obesity.6,7 In NAP SACC, child care directors complete self-assessments of their nutrition, active play, and screen time practices and receive training and technical assistance to implement changes that create healthier environments. Integrating NAP SACC into Reaching for the Stars would incentivize and support participation in the program and broaden its availability.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of integrating NAP SACC into Reaching for the Stars over 10 years with costs and outcomes associated with not implementing the program. This model assumes that 67% of OK children in child care centers and 36% in family child care homes attend a program at Level 2 or higher in Reaching for the Stars and thus will benefit. The model also accounts for swapping out some existing childhood obesity trainings for NAP SACC, making NAP SACC implementation a less costly approach.

Implementing NAP SACC in child care programs throughout Oklahoma is an investment in the future. By the end of 2025:
Chart summarizing the conclusions and implications of the brief

Conclusions and Implications

Every child deserves a healthy start in life. This includes ensuring that all kids in child care have opportunities to eat healthy foods and be physically active, no matter where they live or where they go for child care. A state-level initiative to bring NAP SACC to Oklahoma’s child care programs through Reaching for the Stars could prevent almost 1,600 cases of childhood obesity in 2025 and ensure healthy child care environments for 140,000 of Oklahoma’s young children.

For every $1.00 spent on implementing NAP SACC in Reaching for the Stars, we would save $0.15 in health care costs. These results reinforce the importance of investing in prevention efforts, relative to other treatment interventions, to reduce the prevalence of obesity. Shortchanging prevention efforts can lead to more costly and complicated treatment options in the future, whereas introducing small changes to young children can help them develop healthy habits for life.

Evidence is growing about how to help children achieve a healthy weight. Programs such as NAP SACC are laying the foundation for a healthier future by helping child care providers create environments that nurture healthy habits. Leaders at the federal, state, and local level should use the best available evidence to determine which evidence-based programs and policies hold the most promise to help children eat healthier diets and be more active.

References

  1. Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in Obesity Among Adults in the United States, 2005 to 2014. JAMA. 2016 Jun 7;315(21):2284-91.
  2. Ogden CL, Carroll MD, Lawman HG, Fryar CD, Kruszon-Moran D, Kit BK, Flegal KM. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016 Jun 7;315(21):2292-9.
  3. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Health Affairs. 2009;28(5).
  4. Gortmaker SL, Wang YC, 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 (Millwood). 2015 Nov;34(11):1932-9.
  5. Oklahoma Department of Health Services (DHS). Early Care & Education Licensing Database (2016)
  6. Ward DS, Benjamin SE, Ammerman AS, Ball SC, Neelon BH, Bangdiwala SI. Nutrition and physical activity in child care: results from an environmental intervention. Am J Prev Med. 2008 Oct;35(4):352-6.
  7. Alkon A, Crowley AA, Neelon SE, Hill S, Pan Y, Nguyen V, Rose R, Savage E, Forestieri N, Shipman L, Kotch JB. Nutrition and physical activity randomized control trial in child care centers improves knowledge, policies, and children’s body mass index. BMC Public Health. 2014 Mar 1;14:215.
Suggested Citation:

Macedo C, Case S, Simpson K, Khan F, U’ren S, Giles CM, Flax CN, Cradock AL, Gortmaker SL, Ward ZJ, Kenney EL. Oklahoma: Nutrition and Physical Activity Self-Assessment For Child Care (NAP SACC) Intervention {Issue Brief}. Oklahoma State Department of Health and Oklahoma State Department of Human Services, Oklahoma City, OK, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; October 2017.

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

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the Oklahoma Department of Health and Human Services through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. Funded by The JPB Foundation. Results are those of the authors and not the funders.

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Brief: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) Intervention in New Hampshire

The information in this brief is intended for educational use only.

This brief summarizes a CHOICES Learning Collaborative Partnership simulation model in New Hampshire examining a potential strategy to expand child care providers’ access to the Nutrition and Physical Activity Self-Assessment for Child Care (Go NAP SACC) by targeting the state’s largest providers via contracted training and technical assistance.

The Issue

Over the past three decades, more and more people have developed obesity.1 Today, nearly nine percent of 2-5 year olds have obesity.2 Now labeled as an epidemic, health care costs for treating obesity-related conditions such as heart disease and diabetes were $147 billion in 2008.3 While multiple strategies are needed to reverse the epidemic, emerging prevention strategies directed at children show great promise.4 A large body of evidence shows that healthy eating, physical activity, and less time watching TV helps kids grow up at a healthy weight.

In New Hampshire, 40% of 2-5 year olds attend licensed child care centers; 24% attend a large center or family child care program.5 Making NAP SACC more available can encourage and empower programs to voluntarily improve nutrition, physical activity, and screen time standards.

About NAP SACC and Expanding Access for NH Child Care Programs

Go NAP SACC is an evidence-based, trusted intervention that helps child care programs improve practices for nutrition, active play, and screen time and can reduce childhood obesity.6,7 Child care providers complete self-assessments of their nutrition, active play, and screen time practices and receive training and technical assistance to implement self-selected changes to create healthier environments. Increasing the number of provider slots offered through a contract with child care training and technical assistance specialists at Keene State College, managed by New Hampshire’s Department of Health and Human Services, Division of Public Health Services (DPHS), could broaden the current reach of the Go NAP SACC project, allowing more licensed child care programs to improve nutrition and physical activity policies and practices. Currently, Keene State works with 22 child care providers. Since 2010, over ninety licensed child care programs, caring for nearly 8,000 children, have participated in DPHS funded opportunities to improve 465 nutrition and physical activity policies and practices.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of expanding New Hampshire’s NAP SACC program led by partners at Keene State College over 10 years.

Implementing NAP SACC in New Hampshire’s largest child care programs is an investment in the future. By the end of 2025:
Impact and cost summary of expanding New Hampshire’s NAP SACC program

Conclusions and Implications

Every child deserves a healthy start in life. This includes ensuring that all kids in child care have opportunities to eat healthy foods and be physically active, no matter where they live or where they go for child care. A state-level initiative to bring NAP SACC to New Hampshire’s largest child care programs by expanding its current opportunities could prevent over 600 cases of childhood obesity in 2025 and ensure healthy child care environments for 40,000 young children.

A separate model examined the potential for expanding access to Go NAP SACC via the state’s Quality Rating Improvement System, which is a single-tiered system referred to as Licensed Plus. While such an initiative could be a useful policy tool for creating sustainable access to Go NAP SACC for NH child care providers, the results of that model indicated that fewer children (12,000) would be reached and fewer cases of obesity prevented in 2025 (100) at a slightly higher cost per child ($81). The results of the two models suggest that New Hampshire’s current contracted strategy targeting the state’s largest providers may be more cost-effective. Results from both models reinforce the importance of investing in prevention efforts to reduce the prevalence of obesity. Shortchanging prevention efforts can lead to more costly and complicated treatment options in the future, whereas introducing small changes to young children can help them develop healthy habits for life.

The first few years of childhood may be the best time to promote healthy eating behaviors in children. Programs such as Go NAP SACC lay the foundation by helping child care providers create environments to nurture healthy eating habits and increase opportunities for physical activity for all of the children.

References

  1. Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in Obesity Among Adults in the United States, 2005 to 2014. JAMA. 2016 Jun 7;315(21):2284-91.
  2. Ogden CL, Carroll MD, Lawman HG, Fryar CD, Kruszon-Moran D, Kit BK, Flegal KM. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016 Jun 7;315(21):2292-9.
  3. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Health Affairs. 2009;28(5).
  4. Gortmaker SL, Wang YC, 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 (Millwood). 2015 Nov;34(11):1932-9.5
  5. Child Care Aware. State Child Care Facts in the State of New Hampshire, 2016. Accessed 8/17/17 at: http://childcareaware.org/wp-content/uploads/2016/08/New-Hampshire.pdf; Personal communication from NH Division of Public Health Services.
  6. Ward DS, Benjamin SE, Ammerman AS, Ball SC, Neelon BH, Bangdiwala SI. Nutrition and physical activity in child care: results from an environmental intervention. Am J Prev Med. 2008 Oct;35(4):352-6.
  7. Alkon A, Crowley AA, Neelon SE, Hill S, Pan Y, Nguyen V, Rose R, Savage E, Forestieri N, Shipman L, Kotch JB. Nutrition and physical activity randomized control trial in child care centers improves knowledge, policies, and children’s body mass index. BMC Public Health. 2014 Mar 1;14:215.
  8. Birch, L., Savage, J. S., & Ventura, A. (2007). Influences on the Development of Children’s Eating Behaviours: From Infancy to Adolescence. Canadian Journal of Dietetic Practice and Research : A Publication of Dietitians of Canada = Revue Canadienne de La Pratique et de La Recherche En Dietetique : Une Publication Des Dietetistes Du Canada, 68(1), s1–s56.
Suggested Citation:

Kenney EL, Giles CM, Flax CN, Gortmaker SL, Cradock AL, Ward ZJ, Foster S, Hammond W. New Hampshire: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) Intervention {Issue Brief}. New Hampshire Department of Health and Human Services, Concord, NH, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; October 2017.

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

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the New Hampshire Department of Health and Human Services through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. Funded by The JPB Foundation. Results are those of the authors and not the funders. For more information, please visit: https://www.dhhs.nh.gov

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Brief: NAP SACC in Early Achievers in Washington State

The information in this brief is intended for educational use only.

This brief provides a summary of the CHOICES Learning Collaborative Partnership simulation model of integrating the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) into Washington’s Quality Rating and Improvement System (QRIS), Early Achievers, which awards quality ratings to early care and education (ECE) programs meeting defined standards.

The Issue

Over the past three decades, more and more people have developed obesity.1 Today, nearly nine percent of 2-5 year olds have obesity.2 Health care costs for treating obesity-related health conditions such as heart disease and diabetes were $147 billion in 2008.3 Emerging prevention strategies directed at children show great promise for addressing this issue.4 A large body of evidence shows that healthy eating, physical activity, and limited screen media time (like watching TV or smartphones) helps kids grow up at a healthy weight.

In Washington, over a quarter of 2-5 year olds attend a licensed ECE program.5 Because QRIS systems like Early Achievers incentivize ECE programs to meet high standards and provide training, they are an ideal way to help ECE programs engage in improving nutrition, physical activity, and screen time practices. The Department of Early Learning invested $91 million in Early Achievers in 2016-17.5

About NAP SACC and QRIS

NAP SACC, based on the best available scientific evidence, helps ECE providers improve nutrition, active play, and screen time practices.6,7 QRIS programs encourage providers to improve in quality by using a voluntary and rewarding (rather than regulatory and punitive) approach and offers a mechanism for implementing a time-intensive program like NAP SACC. ECE directors complete self-assessments of existing practices and receive training and technical assistance to implement changes that create healthier environments. In Washington’s hypothetical model, completing NAP SACC would be an option for ECE providers seeking to achieve Early Achievers Level 3 status. State-contracted coaches would train providers and conduct technical assistance for meeting NAP SACC goals.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of integrating NAP SACC into Early Achievers over 10 years (2015-2025) with costs and outcomes associated with not implementing the program. The approach assumes that 72% licensed ECE centers participate in Early Achievers, and 25% of both center-based and home-based providers adopt NAP SACC.

Implementing NAP SACC in child care programs throughout Washington is an investment
in the future. By the end of 2025:

Chart summarizing the conclusions and implications of the brief

Conclusions and Implications

Every child deserves a healthy start in life. This includes ensuring that all kids in child care have opportunities to eat healthy foods and be physically active, no matter where they live or where they go for child care. A state-level initiative to bring the NAP SACC self-assessment and improvement process to Washington child care programs through the Early Achievers system could prevent over a thousand cases of childhood obesity in 2025 and ensure healthy child care environments for over 160,000 children. For every $1 spent implementing this strategy with child care centers, we would save $0.08 in health care costs as a result of decreased obesity prevalence. For every $1 spent implementing this strategy with family home providers, we would save $0.02 in health care costs as a result of decreased obesity prevalence

These results reinforce the importance of investing in prevention efforts, to reduce the prevalence of obesity. Shortchanging prevention efforts can lead to more costly and complicated treatment options in the future. Introducing small changes to young children can help them develop healthy habits for life.

Evidence is growing about how to help children achieve a healthy weight. Programs such as NAP SACC are laying the foundation for healthier generations by helping ECE providers create environments that nurture healthy habits. Leaders at the federal, state, and local level should use the best available evidence to help children eat healthier diets and be more active.

References

  1. Flegal, K.M., Kruszon-Moran, D., Carroll, M.D., Fryar, C.D., Ogden, C.L. (2016). Trends in Obesity Among Adults in the United States, 2005 to 2014. JAMA, 315(21), 2284-91.
  2. Ogden, C. L., Carroll, M. D., Lawman, H. G., Fryar, C. D., Kruszon-Moran, D., Kit, B. K., & Flegal, K. M. (2016). Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013–2014. JAMA, 315(21), 2292-2299.
  3. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Health Affairs. 2009;28(5).
  4. Gortmaker, S. L., Wang, Y. C., Long, M. W., Giles, C. M., Ward, Z. J., Barrett, J. L., …Cradock, A. L. (2015). Three interventions that reduce childhood obesity are projected to save more than they cost to implement. Health Affairs, 34(11), 1932–1939.
  5. DEL Early Achievers Data Dashboard and Market Rate Report, June 2015; Early Start Act Report.
  6. Ward, D.S., Benjamin S.E., Ammerman, A.S., Ball, S.C., Neelon, B.H., Bangdiwala, S.I. (2008). Nutrition and physical activity in child care: results from an environmental intervention. Am J Prev Med, 35(4):352-6.
  7. Alkon, A., Crowley, A.A., Neelon, S.E., Hill, S., Pan, Y., Nguyen, V., Rose, R., Savage, E., Forestieri, N., Shipman, L., Kotch, J.B. (2014). Nutrition and physical activity randomized control trial in child care centers improves knowledge, policies, and children’s body mass index. BMC Public Health, 14:215.
Suggested Citation:

Cradock AL, Gortmaker SL, Pipito A, Kenney EL, Giles CM. Washington: NAP SACC: Researching an Intervention to Create the Healthiest Next Generation [Issue Brief]. Washington State Department of Health, Olympia, WA, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; August 2017.

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

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the Washington State Department of Health through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. Funded by The JPB Foundation. Results are those of the authors and not the funders. For more information, please visit: http://www.doh.wa.gov/CommunityandEnvironment/HealthiestNextGeneration/CHOICES

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