Cost-effectiveness of Obesity Prevention Strategies: Steve Gortmaker, Ph.D. Harvard School of Public Health Childhood Obesity Prevention Coalition

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

30

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

39

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!

42

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

43

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

44

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

48

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