Post on 03-Jul-2015
Improving Lifestyles, Tackling
Obesity: Assessing the Health
and Economic Impact of
Prevention Strategies
Michele Cecchini MD, MSc
Health Policy Analyst, OECD
Chronic Diseases and Prevention
• Increasing prevalence of chronic diseases in the OECD area
– Incidence is increasing (ageing, lifestyles)
– Mortality is decreasing (better healthcare)
• Some risk factors are declining (e.g. smoking)…
• … but others are rising (e.g. unhealthy diet and physical inactivity)
• Prevention or treatment?
Are Prevention Interventions Justified?
It is better to be healthy than ill or dead.
That is the beginning and the end of the only real argument for preventive medicine.
It is sufficient.
Geoffrey Rose
The Goals of Prevention
Prevention may offer opportunities to:
• Increase social welfare
• Enhance health equity
Relative to a situation in which chronic diseases are treated when they emerge
“Maintaining good health is an important goal for most individuals, but health is by no means the only outcome that individuals value when they choose how to lead their own lives. Individuals wish to engage in activities from which they expect to derive pleasure, satisfaction, or fulfilment, some of which may be conducive to good health, others less or not at all. […] An assessment of the role of prevention must not ignore those competing goals” (Sassi and Hurst, 2008)
Are Prevention Interventions Justified?
• Market and rationality failure: – Externalities
– Information failures
– Supply-side market failures
– Failures of rationality
• Existing policies have undesired effects
• Health inequalities
Are Prevention Interventions Justified?
Education and Smoking
From D. Kenkel’s presentation at OECD Expert Group meeting, 27 April 2007.
Smoking risk knowledge and degree Smoking prevalence and degree
Concerns About Rising Obesity
• Evidence consistently shows rising overweight and obesity rates in OECD area
• No sign of decline or slowdown
• BMI distributions are shifting following similar patterns across countries and over time
• Countries with the lowest overweight prevalence today will have caught up with high prevalence rates within 10 years
Obesity: a Growing Problem
20%
30%
40%
50%
60%
70%
80%
1970 1980 1990 2000 2010 2020
Pro
po
rtio
n o
verw
eigh
t (a
du
lt p
op
ula
tio
n)
Year
USA England
Spain
Austria
France
Australia
Canada
Korea
Italy
What Policy Options?
Interventions assessed on the basis of interference with individual choice:
1. Actions that widen the choice set or decrease the price (opportunity cost) of selected choice options;
2. Actions that influence choices through means other than prices, such as persuasion, provision of information, or other suitable means;
3. Actions that increase the price (opportunity cost) of selected choice options;
4. Actions that restrict the choice set by banning selected choice options
What Policy-Makers Want to Know
• Does prevention improve health?
• Does it reduce health expenditure?
• Does it improve health inequalities?
• Is it cost-effective?
Expectations Must Be Realistic
0%
4%
8%
12%
16%
20%
24%
28%
32%
36%
Cost-saving < 10,000 10,000 to 50,000
50,000 to 100,000
100,000 to 250,000
250,000 to 1,000,000
≥ 1,000,000
increases cost and worsen health
Pro
po
rtio
n o
f p
ub
lish
ed
co
st-e
ffec
tiv
enes
s ra
tio
s
Cost-effectiveness ratio ($ per QALY)
Preventive measures Treatments for existing conditions
Adapted from Cohen JT, et al. NEJM 2008;358(7):661-3
Physical activity P0 adequate physical act
P1 insuff .physical act
Body mass
index N normal weight
U pre-obesity
V obesity
Blood pressure Z0 normal
Z1 hypertension
Cholesterol
A0 normal
A1 hypercholesterolemia
Glycaemia B0 normal
B1 diabetes
Cancers
Stroke
Ischemic heart
disease
Distal risk factors Intermediate risk
factor Proximal risk factors Diseases
Fat F0 low fat intake
F1 medium fat intake
F2 high fat intake
Fibre Y0 adequate fibre intake
Y1 low fibre intake
Socio-economic status I0 upper
I1 lower
Interventions
Health education and health promotion
Regulation and fiscal measures
Primary-care based interventions
Mass media campaigns Fiscal measures
(fruit and vegetables and foods high in fat)
Physician counselling of individuals at risk
School-based interventions
Government regulation or industry self-regulation of
food advertising to children
Intensive physician and dietician counselling of
individuals at risk
Worksite interventions Compulsory food
labelling
Scope of Modelling Work
Regional analysis Country analyses
Does Prevention Improve
Population Health?
Health Outcomes of Prevention
0 100,000 200,000 300,000 400,000 500,000
physician-dietician counselling
fiscal measures
physician counselling
food labelling
worksite interventions
food advertising regulation
school-based interventions
food adverting self-regulation
mass media campaigns
Disability-adjusted life years Life years
1 LY/DALY every 115/121 people
1 LY/DALY every 12/10 people
Health Outcomes over Time England
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
0 10 20 30 40 50 60 70 80 90 100
DA
LYs
(pe
r m
illio
n p
op
ula
tio
n)
Time (years)
school-based interventions
worksite interventions
mass media campaigns
fiscal measures
physician counselling
physician-dietician counselling food advertising regulation food adverting self-regulation
food labelling
Intervention Effectiveness (coverage)
Working for large employer [63%]
Employed [64%]
Population aged 18-65 [64%]
Participating
employers [50%]
Participating
employees
[45%]
Coverage = 5.8% of the population
Worksite interventions
Intervention Effectiveness (Time to Steady State)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 98 99 100
1
2
3
90
91
age
pe
rio
d
0 10 20 30 40 50 60 70 80 90 100
school-based int
food advert reg
food advert self-reg
worksite interv
physician couns
phys/diet couns
mass media camp
food labelling
fiscal measures
years to steady state
Does Prevention Reduce
Expenditure on Health Care?
Financial Impacts
-50
50
150
250
350
450
550
Co
st
(bil
lio
n $
PP
P)
intervention costs health expenditure
Health Outcomes and Expenditure Physician-Dietician Counselling
-15000-10000-10000
Health outcomes Impact on health expenditure
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
life years (thousands) DALYs (thousands)
-15,000
-10,000
-5,000
0
5,000
10,000
costs (million $PPP)
Interventions vs. Age
0.95
1.00
1.05
1.10
1.15
Intervention (50 yrs old) Age (51 vs 50)
Change in risk of IHD
Note: risk equals to 1 for 50 year olds and no intervention
Does Prevention Improve
Health Inequalities?
Impact on Inequalities
Different social groups have:
• Different risk profiles:
– Larger benefits in those most at risk (~)
• Different responses to interventions:
– Larger benefits with a greater response
Impact on Inequalities
0.0%
0.1%
0.2%
0.3%
0.4%
0.5%
0.6%
0.7%
high SES low SES
Worksite interventions Fiscal measures
0.0%
0.1%
0.2%
0.3%
0.4%
0.5%
0.6%
0.7%
high SES low SES
Is Prevention Cost-Effective?
Cost-Effectiveness of Prevention
0
50,000
100,000
150,000
200,000
250,000
300,000
10 20 30 40 50 60 70 80 90 100
Co
st-e
ffe
ctiv
en
ess
rati
o (
$P
PP
pe
r D
ALY
)
Years after initial implementation
school-based interventions worksite interventions mass media campaigns
fiscal measures physician counselling physician-dietician counselling
food advertising regulation food adverting self-regulation food labelling
Cost-effectiveness of Prevention after 20 years
-30
0
30
60
90
120
150
0 1 2 3 4 5 6 7 8 9 10
Co
st
(an
nu
al
av
er
ag
e,
bil
lio
n $
PP
P)
Effect (average annual DALY gain, millions)
phys-diet couns
phys couns
fiscal measures
food labelling
worksite interv
food adv self-reg
‡ food adv reg
mass media camp
* school-based int
‡
*
-50
0
50
100
150
200
250
0 2.5 5 7.5 10 12.5 15 17.5 20
Co
st
(an
nu
al
av
er
ag
e,
bil
lio
n $
PP
P)
Effect (average annual DALY gain, millions)
phys-diet couns phys couns
worksite interv
food labelling
fiscal measures food adv self-reg
food adv reg
school-based int
mass media camp
Cost-effectiveness of Prevention after 100 years
The role of prevention packages
Multiple interventions Health outcomes Impact on health expenditure
(selected diseases)
Multiple int. 1 school-based intervention + mass media camp + physician-dietician counselling
Multiple int. 2 food labelling + food advert self-regulation + school-based interventions + mass media campaigns + physician-dietician counselling
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
Life years (thousands)
Disability-adjusted life years (thousands)
-70,000
-60,000
-50,000
-40,000
-30,000
-20,000
-10,000
0
Impact on health expenditure (million $PPP)
Multiple Interventions
0 50 100 150 200 250 300 350 400
Cost-effectiveness ratio (thousand $PPP per DALY)
50
,00
0 $
PP
P/D
AL
Y
mo
re t
ha
n 1
,00
0,0
00
$P
PP
/DA
LY
0 25 50 75 100
Cost-effectiveness ratio (thousand $PPP per DALY)
50
,00
0 $
PP
P/D
AL
Y
Fiscal measures
Mass media camp
Phys-diet couns.
Food labelling
Multiple int. 2
Multiple int. 1
Physician couns.
Worksite interv.
Food adv self-reg.
Food advert.
School-based int.
Cost-effectiveness of interventions after 10 years Cost-effectiveness of interventions after 100 years
Policy Implications
• Prevention is an effective and cost-effective way to improve population health
• Prevention can decrease health expenditure and improve inequalities, but not to a major degree
• Comprehensive strategies combining population and individual approaches provide best results
• Involvement of relevant stakeholders is key to the success of prevention
OECD work on prevention
• Obesity and the economics of prevention: fit not fat
• OECD health working papers HWP 32, 45, 46, 48
• Paper in Lancet series on chronic diseases (forthcoming)
www.oecd.org/health/prevention www.oecd.org/health/fitnotfat michele.cecchini@oecd.org