Cost-effectiveness of Obesity Prevention Strategies: Steve Gortmaker, Ph.D. Harvard School of...
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Cost-effectiveness of Obesity Prevention Strategies:
Steve Gortmaker, Ph.D.Harvard School of Public Health
Childhood Obesity Prevention CoalitionDec 3, 2013
Supported by grants from CDC (1U48DP001946), including the Nutrition and Obesity Policy, Research and Evaluation Network, the Robert Wood Johnson Foundation, and the JPB Foundation. This work is solely the responsibility of the authors and does not represent official views of the Centers for Disease Control and Prevention or any of the other funders.
Outline for Today
• What changes do we need to alter child obesity in the US? The energy gap
• Lancet Series: causes, trends and best value for money policies and programs
• CHOICES cost effectiveness modeling in US– SSB tax, School based physical activity, reducing
marketing to children• Recent Boston Initiatives• Implications for Action
Cover ofThe Economist
the energy gapClaire Wang & Steve Gortmaker
Energy Gap Framework: Rationale Excess weight gain during growth is a result of energy intake exceeding expenditure. Measuring underlying drivers of population weight shift informs surveillance, goal setting and benchmarking progress.
Definition:Imbalance between calories children consume each day and calories required to support normal growth, physical activity, and body function.
Reference: Wang YC, Gortmaker SL, Sobol AM, Kuntz KM. Pediatrics 2006. 118 (6): 1721-1733
Translating Excess Weight Gain toDaily Energy Gap
Assumptions3500 kcal accumulated= 1 lb weight gain as fatEfficiency of energy storage from food: 50-75%Linear accumulation of excess weight over 10 yAdjustment for higher energy expenditure following
weight gain
Energy Balance (EB)Kcal in Kcal out
Body Weight (Kg)
Average Daily Energy Gap (kcal/day): 1988-94 to1999-2002
Excess Weight Gained
(Lb)Daily Energy Gap
(kcal/day)All Teens 10 110 -165
Behavioral implications of 150 kcal for an average kid: Replacing 1 can of soda (12 oz) with water (140 kcal) Reducing TV watching by an hour (100 kcal/day) Walking ~1.9 hours instead of sitting Increasing PE from 1 to 3 times/week (240 kcal)
The Energy Gap and Recent Obesity Trends
Increasing childhood obesity in USWhat will it take to halt, or reverse these trends so we can reach the Healthy People goals?
Wang, Orleans, Gortmaker. (2012) Reaching the Healthy People Goals for Reducing Childhood Obesity: Closing the Energy Gap. Am J Prev Med.
64.
Recent work of Hall• The bodyweight response to a change of
energy intake is slow, with half times of about 1 year
• An adult with a BMI higher than 35 kg/m², (14% of US population), needs a change greater than 500 kcal per day to return to the average bodyweight of the 1970s
• Children have much less excess weight!
Hall KD, Sacks G, Chandramohan D, Chow CC, Wang YC, Gortmaker SL, Swinburn BA. Quantification of the effect of energy imbalance on bodyweight. Lancet. 2011 Aug 27;378(9793):826-37.
Science, Policy and Action
•Governments need to lead obesity prevention, but so far few have shown leadership•It is crazy that we do effectiveness studies and do not measure intervention costs•Empirical evidence of how to prevent obesity is limited but growing: cost-effectiveness policy and program analyses indicate several are both effective and cost saving
Gortmaker, Swinburn, Levy et al. Changing the future of obesity: science, policy, and action, Lancet 2011; 378: 838–47.
Evidence for Leveling Off Childhood Overweight/Obesity Rates
Happening all over US In MA 2009-2012 75% of school districts had
decreasing trend1 Boston rates 2009-11 decline from 42.6 to 39.9
(N of 12,000/year) =>Evidence for change – but rates still at
historically high levels
1 Wenjun Li, James Buszkiewicz, Robert Leibowitz, Anne Sheetz, Laura York, Thomas Land. Trends in overweight and obesity
prevalence in Massachusetts school districts (2009-2013). Poster presented at New Balance Obesity Conference, Boston, MA 2013.
2 The Status of Childhood Weight in Massachusetts, 2011. Preliminary Results from Body Mass Index Screening in Massachusetts
Public School Districts, 2009-2011. Massachusetts Department of Public Health. 2012.
CHOICES Pilot StudyModeling the Cost Effectiveness of
Childhood Obesity Interventions in the United States
When you talk to decision makers about your work (what you can do to improve childhood obesity), they want to know three things• What is feasible (the intervention,
program, policy)?• How effective is it?• What will it cost?
Why Cost Effectiveness?
Cost-effectiveness Plane
Difference in Effectiveness
Diffe
renc
e in
Cos
t
+
+-
-
Higher costs Worse outcome
Lower costs Better outcome
Higher costs Better outcome
Lower costs Worse outcome
We cannot afford all the childhood obesity interventions we’d like to implement, so why not begin with those producing the “biggest bang for the buck?”
Why Cost Effectiveness?
• Originally funded by Robert Wood Johnson Foundation
• Adapted Australian ACE (Assessing Cost Effectiveness) methodology• ACE Prevention and ACE Obesity
• Continued work with JPB funding • CHOICES project (CHildhood ObesIty Cost
Effectiveness Study)
Pilot Cost-effectiveness Models
• Harvard (Gortmaker, Cradock, Giles, Weinstein, Resch, Ward, Long, Barrett, Sonneville, Wright)
• Columbia University (Wang)• Deakin (Swinburn, Carter, Moodie, Sacks)• Queensland (Vos, Barendregt)
CHOICES Team for Pilot
• Recruitment of a stakeholder group • Selection of interventions• Specification of the Intervention,
implementation and costing• Intervention effects evidence synthesis • Modeling short and long term cost
effectiveness • Uncertainty and sensitivity analyses• Implementation and equity considerations
Key Methods in CHOICES
• US policy makers and researchers• Nutrition/physical activity researchers• Programmatic experts• Provide advice on specification of
interventions, data sources, implementation
Recruitment of Stakeholder Group
• Selected by investigators, with stakeholder input
• Both nutrition and physical activity interventions
• Both policy and programmatic• Interventions can be clearly specified• Can be spread throughout US
Selection of Interventions
InterventionImplementation
Intervention recruitment
The CHOICES Logic Model
DALYSQALYSHealth care costs averted
BMI and Obesity
InterventionImplementation
Intervention recruitment
Costs of • intervention• current
practice Long term Outcomes: health care
offsets$cost/DALY
Intervention, Effects, and Costing
DALYSQALYSHealth care costs averted
BMI and Obesity
Short term outcomes: $cost/BMI
InterventionImplementation
Intervention recruitment
Costs of • intervention• current
practice Long term Outcomes: health care
offsets$cost/DALY
Intervention, Effects, and Costing
DALYSQALYSHealth care costs averted
BMI and Obesity
Short term outcomes: $cost/BMI
InterventionImplementation
Intervention recruitment
Costs of • intervention• current
practice Long term Outcomes: health care
offsets$cost/DALY
Intervention, Effects, and Costing
DALYSQALYSHealth care costs averted
BMI and Obesity
Short term outcomes: $cost/BMI
InterventionImplementation
Intervention recruitment
Costs of • intervention• current
practice Long term Outcomes: health care
offsets$cost/DALY
Intervention, Effects, and Costing
DALYSQALYSHealth care costs averted
BMI and Obesity
Short term outcomes: $cost/BMI
• Level of evidence (pathway to BMI)• Equity and impact on disparities• Acceptability to stakeholders• Feasibility• Sustainability• Side effects• Social and policy norms
Implementation and Equity Considerations
Potential Impact of a Sugar-sweetened Beverage Excise Tax on BMI, Disability Adjusted Life Years, and Healthcare Costs in the United States (Long)
Cost-effectiveness of a state policy requiring minimum levels of moderate-to-vigorous physical activity during elementary school physical education classes (Barrett)
Potential Impact of Eliminating the Tax Subsidy of Food and Beverage Television Advertising Directed at Children and Adolescents on BMI, DALYs, and Healthcare Costs in the United States (Sonneville)
Evidence from Pilot Interventions
SSB Excise Tax Intervention
In 2012 8 states and 2 cities considered legislation to increase SSB taxes, although none passed1
The modeled intervention consists of:
An excise tax of one cent per ounce of SSB, applied nationally and administered at the state level
291 Yale Rudd Center SSB Excise Tax Map, 2012
Active PE Intervention
Implementation of a state policy directing the U.S. state boards of education to include a requirement for 50% of PE time to be devoted to MVPA in the state PE curriculum for the elementary school level
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Based on policies passed by state legislatures in Texas (SB 891, 2009) & Oklahoma (SB 1876, 2010)
Implemented within existing PE time provided Children are exposed on ~2 days/week during the
school year from the ages of 5-11 years
TV Advertising Intervention
Eliminate the tax deductibility of TV advertising costs for nutritionally poor foods and beverages advertised to children and adolescents ages 2-19
• Computer simulation model 2005 US population
• Use @Risk and compiled programming model for uncertainty analyses: 10,000 iterations
• Short-term Outcomes: Effects on BMI compared to natural history
• Long-term Outcomes: BMI-mediated reductions in incidence of 9 diseases
• Estimated disability-adjusted life years (DALYs) averted and healthcare cost savings
• Discounted health effects and costs at 3.5%
Conduct uncertainty and scenario analyses
• All interventions show evidence for effectiveness
• Widely varying:• Reach (population)• Total cost of intervention• Per person BMI change (those in the
intervention)• Short Term Cost effectiveness
($cost/BMI)
Comparison of Results
Intervention Reach Millions
Total Cost US $ Millions
Per Person BMI Unit Reduction
Cost per unit BMI reductionUS$Age 2-19
SSB Excise Tax (all ages)
287 $147 0.19 $6.44
Active PE in School (age 5-11)
16.6 $54.7 0.02 $191
TV Advertising Change (age 2-19)
74 $0.8 0.13 $0.08
Overview of Short Term Outcomes
Intervention Reach Millions
Total Cost US $ Millions
Per Person BMI Unit Reduction
Cost per unit BMI reductionUS$Age 2-19
SSB Excise Tax (all ages)
287 $147 0.19 $6.44
Active PE in School (age 5-11)
16.6 $54.7 0.02 $191
TV Advertising Change (age 2-19)
74 $0.8 0.13 $0.08
Overview of Short Term Outcomes
Intervention Reach Millions
Total Cost US $ Millions
Per Person BMI Unit Reduction
Cost per unit BMI reductionUS$Age 2-19
SSB Excise Tax (all ages)
287 $147 0.19 $6.44
Active PE in School (age 5-11)
16.6 $54.7 0.02 $191
TV Advertising Change (age 2-19)
74 $0.8 0.13 $0.08
Overview of Short Term Outcomes
Intervention Reach Millions
Total Cost US $ Millions
Per Person BMI Unit Reduction
Cost per unit BMI reductionUS$Age 2-19
SSB Excise Tax (all ages)
287 $147 0.19 $6.44
Active PE in School (age 5-11)
16.6 $54.7 0.02 $191.00
TV Advertising Change (age 2-19)
74 $0.8 0.13 $0.08
Overview of Short Term Outcomes
• High Five Intervention: $1000/BMI unit change1
• Bariatric Surgery: One estimate can be derived by assessing the average cost divided by average change in BMI.2-3 This indicates a cost of about $3000/BMI unit change
1 Wright, et al. Paper under review2 Kelleher DC, Merrill CT, Cottrell LT, Nadler EP, Burd RS. Recent national trends in the use of adolescent inpatient bariatric surgery: 2000 through 2009. JAMA Pediatr. 2013;167(2):126-132.3 Black JA, White B, Viner RM, Simmons RK. Bariatric surgery for obese children and adolescents: a systematic review and meta-analysis. Obes Rev. 2013.
Comparison to Clinical Interventions
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Long-term Outcomes: SSB Excise Tax
Life-Years Saved 4.49 millionDALYs Averted 5.56 millionHealthcare costs saved $47.1 billionHealthcare costs saved per dollar spent
$321
Tax would be cost saving within 1 year of reaching full effect
Assuming effects would be maintained indefinitely:
• Long term cost-effectiveness and cost saving for childhood interventions require maintenance of effect for many years (30+) under current modeling assumptions
Long Term Outcomes: Childhood Interventions
Intervention Increased National Revenue per year US$
SSB Excise Tax (all ages)
$12.4 billion/year
Active PE in School (age 5-11)
-
TV Advertising Change(age 2-9)
$356 million/year
Additional Benefit: Revenue!
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Health Equity: SSB Excise Tax
Concerns regarding potentially regressive nature of SSB excise tax have been raised
Empirical evidence on soda taxes demonstrates greater benefit for overweight children and children in African-American and low-income households1
Substantial revenue can be earmarked for progressive nutrition and public health programs
1 Sturm et al. Health Affairs. 2010;29(5):1052-1058
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Equity Considerations: PE Intervention
PE time requirements may not be as likely in schools with higher percentages of low income students
- Johnston et al. 2007; San Diego State University 2007
So an Active PE policy may have a greater impact among higher income students who have more PE time, and be less likely to reach lower income students
Therefore, potentially inequitable in terms of socioeconomic status
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Equity Considerations: TV Advertising
Because low income and ethnic minority children watch more TV, there is the potential to reduce obesity disparities and related health outcomes via this intervention
Study Goals: • To generate cost effectiveness estimates for 40 of the
most relevant childhood obesity interventions in the United States;
• Using comparable methods• To engage policymakers and the general public in this
issue, and provide guidance so that the most cost effective strategies for action are identified and become a focus of discussion and action.
40 CHOICES Cost Effectiveness Studies
Some New Environmental Change Strategies in Boston:
Get Sugar Sweetened Beverages Out of Schools, Preschools, Afterschools, Government Worksites, Healthcare Institutions – and Assure Water Access
Reported Consumption of Servings (12 oz) per Day of Sugary Drinks, Boston High
School Youth - Before and After Implementation of School Beverage Policy
00.20.40.60.8
11.21.41.61.8
2004 Pre 2006 Post
Boston High School Youth
Change in Boston P<0.001; no change in national sample
1.68 1.40
Boston Youth Survey data were collected via a collaboration between the City of Boston and Harvard School of Public Health. N=1079 in 2004 and 1223 in 2006
OSNAP Initiative• PRC 2010-2014 core research project• In partnership with Boston Public Schools,
YMCA of Greater Boston, Boston Boys and Girls Clubs, Boston Centers for Youth and Families, Boston Public Health Commission
• Builds on PRC work with YMCA of the USA, BPS Food and Nutrition Services
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Goals for Nutrition and Physical Activity in Out-of-School Time
• Include 30 minutes of moderate, fun, physical activity for every child every day
• Offer 20 minutes of vigorous physical activity 3 times per week• Ban sugar-sweetened drinks from snacks served• Offer water as a drink at snack every day• Eliminate use of commercial broadcast TV/movies• Limit recreational computer time to less than one hour per day• Offer a fruit or vegetable option every day at snack• Ban foods with trans fats from snacks served• Ban sugar-sweetened drinks brought in from outside the snack
program
Out of School Nutrition and Physical Activity Initiative
Serving water during afterschool: Impact of Group Randomized Trial
Catherine Giles, Erica Kenney, Steven Gortmaker, Rebekka Lee, Julie Thayer, Helen Mont-Ferguson, Angie Cradock
RCT: Fall 2010-Spring 2011• 20 afterschool programs in Boston• Matched pairs (program partners, lunch
provider, demographics, PA facilities)• 5 days of data collection pre/post• 1097 children in consent pool in Fall• Snack intake collected on 590 students in Fall• Accelerometer data collected on 568 students
in Fall
OSNAP Impact• Intervention effects: increases in times water served
per day (0.59; p<0.001) and ounces of water served per day (3.33: P<0.001)
• The intervention resulted in a 76.0 kcal decrease in beverages offered (p<0.001), mainly by replacing juice with water (servings of milk were unaffected).
• Check out the materials: www.osnap.org– Assessments - Interactive Action Planning– Step-by-Step Topic Specific Guides - Implementation Guides
Giles CM, Kenney EL, Gortmaker SL, Lee RM, Thayer JC, Mont-Ferguson H, Cradock AL. Am J Prev Med. 2012 Sep;43(3 Suppl 2):S136-42.
Menino expands sugary drink ban Some beverages won’t be allowed on city properties
A Coca-Cola machine in front of the Boston Fire Department’s station on Columbus Avenue in the South End. (John Tlumacki/Globe Staff) By Meghan E. Irons Globe Staff / April 8, 2011
Can Cost Effectiveness Research Help to Reverse the Obesity Epidemic?
•Note the first success in tobacco control in retrospect was not really that complex and cost effective strategies were key: reduce marketing, raise taxes to increase price, restrict consumption in public places, combined with some treatment…..these together had a substantial impact•We can alter the course of the obesity epidemic – evidence seems to indicate that policy and regulatory strategies are key and that cost effectiveness evaluation can be critical so efforts is targeted
•Strategies to lower sugar sweetened beverage access should be central to any obesity control strategy