Cost-effectiveness of Obesity Prevention Strategies: Steve
Gortmaker, Ph.D. Harvard School of Public Health Childhood Obesity
Prevention Coalition Dec 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.
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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
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Cover of The Economist
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the energy gap Claire Wang & Steve Gortmaker
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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
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Translating Excess Weight Gain to Daily Energy Gap Assumptions
3500 kcal accumulated= 1 lb weight gain as fat Efficiency of energy
storage from food: 50-75% Linear accumulation of excess weight over
10 y Adjustment for higher energy expenditure following weight gain
Energy Balance (EB) Kcal inKcal out Body Weight (Kg)
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Average Daily Energy Gap (kcal/day): 1988-94 to1999-2002 Excess
Weight Gained (Lb) Daily Energy Gap (kcal/day) All Teens10110 -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)
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The Energy Gap and Recent Obesity Trends Increasing childhood
obesity in US What 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.
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64.
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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/m, (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.
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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: 83847.
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Evidence for Leveling Off Childhood Overweight/Obesity Rates
Happening all over US In MA 2009-2012 75% of school districts had
decreasing trend 1 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.
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CHOICES Pilot Study Modeling the Cost Effectiveness of
Childhood Obesity Interventions in the United States
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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?
We cannot afford all the childhood obesity interventions wed
like to implement, so why not begin with those producing the
biggest bang for the buck? Why Cost Effectiveness?
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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
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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
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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
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US policy makers and researchers Nutrition/physical activity
researchers Programmatic experts Provide advice on specification of
interventions, data sources, implementation Recruitment of
Stakeholder Group
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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
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Intervention Implementation Intervention recruitment The
CHOICES Logic Model The CHOICES Logic Model DALYS QALYS Health care
costs averted BMI and Obesity
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Intervention Implementation Intervention recruitment Costs of
intervention current practice Long term Outcomes: health care
offsets $cost/DALY I I ntervention, Effects, and Costing DALYS
QALYS Health care costs averted BMI and Obesity Short term
outcomes: $cost/BMI
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Intervention Implementation Intervention recruitment Costs of
intervention current practice Long term Outcomes: health care
offsets $cost/DALY I I ntervention, Effects, and Costing DALYS
QALYS Health care costs averted BMI and Obesity Short term
outcomes: $cost/BMI
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Intervention Implementation Intervention recruitment Costs of
intervention current practice Long term Outcomes: health care
offsets $cost/DALY I I ntervention, Effects, and Costing DALYS
QALYS Health care costs averted BMI and Obesity Short term
outcomes: $cost/BMI
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Intervention Implementation Intervention recruitment Costs of
intervention current practice Long term Outcomes: health care
offsets $cost/DALY I I ntervention, Effects, and Costing DALYS
QALYS Health care costs averted BMI and Obesity Short term
outcomes: $cost/BMI
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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
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u Potential Impact of a Sugar-sweetened Beverage Excise Tax on
BMI, Disability Adjusted Life Years, and Healthcare Costs in the
United States (Long) u Cost-effectiveness of a state policy
requiring minimum levels of moderate-to-vigorous physical activity
during elementary school physical education classes (Barrett) u
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) Pilot Interventions Evidence from Pilot
Interventions
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SSB Excise Tax Intervention u In 2012 8 states and 2 cities
considered legislation to increase SSB taxes, although none passed
1 u The modeled intervention consists of: An excise tax of one cent
per ounce of SSB, applied nationally and administered at the state
level 29 1 Yale Rudd Center SSB Excise Tax Map, 2012
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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 30 u Based on
policies passed by state legislatures in Texas (SB 891, 2009) &
Oklahoma (SB 1876, 2010) u Implemented within existing PE time
provided u Children are exposed on ~2 days/week during the school
year from the ages of 5-11 years
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TV Advertising Intervention u Eliminate the tax deductibility
of TV advertising costs for nutritionally poor foods and beverages
advertised to children and adolescents ages 2-19
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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
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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
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Intervention Reach Millions Total Cost US $ Millions Per Person
BMI Unit Reduction Cost per unit BMI reduction US$ Age 2-19 SSB
Excise Tax (all ages) 287$1470.19$6.44 Active PE in School (age
5-11) 16.6$54.70.02$191 TV Advertising Change (age 2-19)
74$0.80.13$0.08 Overview of Short Term Outcomes
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Intervention Reach Millions Total Cost US $ Millions Per Person
BMI Unit Reduction Cost per unit BMI reduction US$ Age 2-19 SSB
Excise Tax (all ages) 287$1470.19$6.44 Active PE in School (age
5-11) 16.6$54.70.02$191 TV Advertising Change (age 2-19)
74$0.80.13$0.08 Overview of Short Term Outcomes
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Intervention Reach Millions Total Cost US $ Millions Per Person
BMI Unit Reduction Cost per unit BMI reduction US$ Age 2-19 SSB
Excise Tax (all ages) 287$1470.19$6.44 Active PE in School (age
5-11) 16.6$54.70.02$191 TV Advertising Change (age 2-19)
74$0.80.13$0.08 Overview of Short Term Outcomes
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Intervention Reach Millions Total Cost US $ Millions Per Person
BMI Unit Reduction Cost per unit BMI reduction US$ Age 2-19 SSB
Excise Tax (all ages) 287$1470.19$6.44 Active PE in School (age
5-11) 16.6$54.70.02$191.00 TV Advertising Change (age 2-19)
74$0.80.13$0.08 Overview of Short Term Outcomes
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High Five Intervention: $1000/BMI unit change 1 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 review 2
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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39 Long-term Outcomes: SSB Excise Tax Life-Years Saved4.49
million DALYs Averted5.56 million Healthcare costs saved$47.1
billion Healthcare costs saved per dollar spent $321 u Tax would be
cost saving within 1 year of reaching full effect u Assuming
effects would be maintained indefinitely:
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Long term cost-effectiveness and cost saving for childhood
interventions require maintenance of effect for many years (30+)
under current modeling assumptions Long Term Outcomes: Childhood
Interventions
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InterventionIncreased National Revenue per year US$ 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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42 Health Equity: SSB Excise Tax u Concerns regarding
potentially regressive nature of SSB excise tax have been raised u
Empirical evidence on soda taxes demonstrates greater benefit for
overweight children and children in African-American and low-income
households 1 u 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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43 Equity Considerations: PE Intervention u 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 u 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 u Therefore,
potentially inequitable in terms of socioeconomic status
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44 Equity Considerations: TV Advertising u 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
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u 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
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Some New Environmental Change Strategies in Boston: Get Sugar
Sweetened Beverages Out of Schools, Preschools, Afterschools,
Government Worksites, Healthcare Institutions and Assure Water
Access
Slide 47
Reported Consumption of Servings (12 oz) per Day of Sugary
Drinks, Boston High School Youth - Before and After Implementation
of School Beverage Policy Change in Boston P