Obesity-Related Policy/Environmental Interventions: A Systematic Review of Economic Analyses

Barriers and Facilitators Related to the Adoption of Policies to Reduce Ultra-Processed Foods Consumption: A Scoping Review

Cost-effective regulatory and fiscal interventions are recommended to address non-communicable diseases. While some countries are advancing regarding these actions, others have found it difficult to approve them.

AIM

to conduct a scoping review to answer the question "What factors have influenced the adoption of food taxes, front-of-pack labeling and restrictions on marketing to children?".

METHODS

A scoping review was developed from four databases. Studies that described and analyzed policy processes were included. Analysis was performed to identify the barriers and enablers mentioned under the guidance of Swinburn et al., Huang et al., Mialon et al., and Kingdon.

RESULTS

168 documents were identified, describing experiences from five regions or groups and 23 countries, which have generated 1584 examples of 52 enablers (689 examples; 43.5%) and 55 barriers (895 examples; 56.5%) that may have influenced policies. The main enablers were related to the government environment and governance and to civil society strategies. Corporate political activity strategies were the main examples of barriers.

CONCLUSIONS

This scoping review consolidated barriers and facilitators related to policies aimed at reducing ultra-processed foods consumption, demonstrating that factors related to the actions of governments and civil society are the main facilitators. On the other hand, as the most interested actor in promoting the consumption of these products, the strategies adopted by the companies that produce these products constitute the main barrier to these policies in all the studied countries and should be overcome.

The intangible costs of overweight and obesity in Germany

BACKGROUND

Previous literature documents the direct and indirect economic costs of obesity, yet none has attempted to quantify the intangible costs of obesity. This study focuses on quantifying the intangible costs of one unit body mass index (BMI) increase and being overweight and obese in Germany.

METHODS

By applying a life satisfaction-based compensation value analysis to 2002-2018 German Socio-Economic Panel Survey data for adults aged 18-65, the intangible costs of overweight and obesity are estimated. We apply individual income as a reference for estimating the value of the loss of subjective well-being due to overweight and obesity.

RESULTS

The intangible costs of overweight and obesity in 2018 amount to 42,450 and 13,853 euros, respectively. A one unit increase in BMI induced a 2553 euros annual well-being loss in the overweight and obese relative to those of normal weight. When extrapolated to the entire country, this figure represents approximately 4.3 billion euros, an intangible cost of obesity similar in magnitude to the direct and indirect costs documented in other studies for Germany. These losses, our analysis reveals, have remained remarkably stable since 2002.

CONCLUSIONS

Our results underscore how existing research into obesity's economic toll may underestimate its true costs, and they strongly imply that if obesity interventions took the intangible costs of obesity into account, the economic benefits would be considerably larger.

Methods for the economic evaluation of obesity prevention dietary interventions in children: A systematic review and critical appraisal of the evidence

OBJECTIVES

We aim to describe and provide a discussion of methods used to conduct economic evaluations of dietary interventions in children and adolescents, including long-term modelling, and to make recommendations to assist health economists in the design and reporting of such evaluations.

METHODS

A systematic review was conducted in 11 bibliographic databases and the grey literature with searches undertaken between January 2000 and December 2021. A study was included if it (1) was an economic evaluation or modelling study of an obesity-prevention dietary intervention and (2) targeted 2- to 18-year-olds.

RESULTS

Twenty-six studies met the inclusion criteria. Twelve studies conducted an economic evaluation alongside a clinical trial, and 14 studies modelled long-term health and cost outcomes. Four overarching methodological challenges were identified: modelling long-term impact of interventions, measuring and valuing health outcomes, cost inclusions and equity considerations.

CONCLUSIONS

Variability in methods used to predict, measure and value long-term benefits in adulthood from short-term clinical outcomes in childhood was evident across studies. Key recommendations to improve the design and analysis of future economic evaluations include the consideration of weight regain and diminishing intervention effects within future projections; exploration of wider intervention benefits not restricted to quality-of-life outcomes; and inclusion of parental or caregiver opportunity costs.

Implementing federal food service guidelines in federal and private worksite cafeterias in the United States leads to improved health outcomes and is cost saving

Poor diet increases cardiometabolic disease risk, yet the impact of food service guidelines on employee health and its cost effectiveness is poorly understood. Federal food service guidelines (FFSG) aim to provide United States (U.S.) government employees with healthier food options. Using microsimulation modeling, we estimated changes in the incidence of cardiometabolic disease, related mortality, and the cost effectiveness of implementing FFSG in nationally representative model populations of government and private company employees across 5 years and lifetime. We based estimates on changes in workplace intake of six FFSG dietary targets and showed lifetime reductions of heart attacks (- 107/million), strokes (- 30/million), diabetes (- 134/million), ischemic heart disease deaths (- 56/million), and stroke deaths (- 8/million). FFSG is cost saving overall, with total savings in discounted healthcare costs from $4,611,026 (5 years) to $539,809,707 (lifetime) $U.S. This study demonstrates that FFSG improves health outcomes and is cost saving.

What are effective policies for promoting physical activity? A systematic review of reviews

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There is a growing need for evidence on the effectiveness of different policies to promote physical activity.

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We conducted a systematic literature review to collate the available evidence.

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We identified 57 reviews with evidence on 53 types of physical activity policies from 7 areas.

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There is a solid evidence base for the effectiveness of school-based and some infrastructural policies.

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The evidence for other (e.g. economic) policies remains insufficient.

The importance of policy for promoting physical activity (PA) is increasingly recognized by academics, and there is a push by national governments and international institutions for PA policy development and monitoring. However, our knowledge about which policies are actually effective to promote PA remains limited. This article summarizes the currently available evidence by reviewing existing reviews on the subject.

Building on results from a previous scoping review on different types of PA-related evidence, we ran searches for combinations of the terms “physical activity”, “evidence”, “effect”, “review”, and “policy” in six different databases (PubMed, Scopus, SportDiscus, PsycInfo, ERIC, and IBSS). We used EPPI Reviewer 4 to further process the results and conduct an in-depth analysis.

We identified 57 reviews providing evidence on 53 types of policies and seven broader groups of policies. Reviews fell into four main categories: 1) setting- and target group-specific; 2) urban design, environment and transport; 3) economic instruments; and 4) broad-range perspective. Results indicate that there is solid evidence for policy effectiveness in some areas (esp. school-based and infrastructural policies) but that the evidence in other areas is insufficient (esp. for economic policies).

The available evidence provides some guidance for policy-makers regarding which policies can currently be recommended as effective. However, results also highlight some broader epistemological issues deriving from the current research. This includes the conflation of PA policies and PA interventions, the lack of appropriate tools for benchmarking individual policies, and the need to critically revisit research methodologies for collating evidence on policies.

Shape Up Somerville's return on investment: Multi-group exposure generates net-benefits in a child obesity intervention

Community-based interventions may reduce and prevent childhood obesity by transforming the environments in which children live, learn, and play through a series of interventions implemented throughout the community that encourage healthy behaviors. While empirical support is building for the effectiveness of such interventions, little is known about the economic costs and benefits of community-wide childhood obesity interventions. This study examined whether the benefits of a community-wide, child-focused, obesity prevention intervention, Shape Up Somerville: Eat Smart Play Hard (SUS), exceeded its costs by estimating its return on investment. The SUS intervention study occurred in Somerville, Massachusetts (and in two additional geographic areas, which were the study's control group) during the 2003/04 and 2004/05 school years. We estimated SUS's costs using SUS data over the two-year intervention. We estimated benefits (i.e., healthcare costs and productivity losses averted for children and their parents) over a ten-year time horizon using SUS effectiveness results and other sources. SUS generated an estimated $1.51 in savings for every $1.00 invested in the program (return on investment of $0.51). Over ten years, the estimated costs averted were over $500,000 with net benefits of $197,120 (2014 dollars). SUS was estimated to be a cost-saving intervention when examined over a ten-year time horizon. The excess benefits generated by SUS likely arose from the community-wide nature of the intervention which extended exposure (and estimated benefits) beyond children to parents as well. These results illustrate that allocating resources to community-wide, child-focused obesity prevention interventions may be a beneficial investment.

Mass media to communicate public health messages in six health topic areas: a systematic review and other reviews of the evidence

Background

Mass media campaigns can be used to communicate public health messages at the population level. Although previous research has shown that they can influence health behaviours in some contexts, there have been few attempts to synthesise evidence across multiple health behaviours.

Objectives

To (1) review evidence on the effective use of mass media in six health topic areas (alcohol, diet, illicit drugs, physical activity, sexual and reproductive health and tobacco), (2) examine whether or not effectiveness varies with different target populations, (3) identify characteristics of mass media campaigns associated with effectiveness and (4) identify key research gaps.

Design

The study comprised (1) a systematic review of reviews, (2) a review of primary studies examining alcohol mass media campaigns, (3) a review of cost-effectiveness evidence and (4) a review of recent primary studies of mass media campaigns conducted in the UK. A logic model was developed to inform the reviews. Public engagement activities were conducted with policy, practitioner and academic stakeholders and with young people.

Results

The amount and strength of evidence varies across the six topics, and there was little evidence regarding diet campaigns. There was moderate evidence that mass media campaigns can reduce sedentary behaviour and influence sexual health-related behaviours and treatment-seeking behaviours (e.g. use of smoking quitlines and sexual health services). The impact on tobacco use and physical activity was mixed, there was limited evidence of impact on alcohol use and there was no impact on illicit drug behaviours. Mass media campaigns were found to increase knowledge and awareness across several topics, and to influence intentions regarding physical activity and smoking. Tobacco and illicit drug campaigns appeared to be more effective for young people and children but there was no or inconsistent evidence regarding effectiveness by sex, ethnicity or socioeconomic status. There was moderate evidence that tobacco mass media campaigns are cost-effective, but there was weak or limited evidence in other topic areas. Although there was limited evidence on characteristics associated with effectiveness, longer or greater intensity campaigns were found to be more effective, and messages were important, with positive and negative messages and social norms messages affecting smoking behaviour. The evidence suggested that targeting messages to target audiences can be effective. There was little evidence regarding the role that theory or media channels may play in campaign effectiveness, and also limited evidence on new media.

Limitations

Statistical synthesis was not possible owing to considerable heterogeneity across reviews and studies. The focus on review-level evidence limited our ability to examine intervention characteristics in detail.

Conclusions

Overall, the evidence is mixed but suggests that (1) campaigns can reduce sedentary behaviour, improve sexual health and contribute to smoking cessation, (2) tobacco control campaigns can be cost-effective, (3) longer and more intensive campaigns are likely to be more effective and (4) message design and targeting campaigns to particular population groups can be effective.

Future work

Future work could fill evidence gaps regarding diet mass media campaigns and new-media campaigns, examine cost-effectiveness in areas other than tobacco and explore the specific contribution of mass media campaigns to multicomponent interventions and how local, regional and national campaigns can work together.

Study registration

This study is registered as PROSPERO CRD42015029205 and PROSPERO CRD42017054999.

Funding

The National Institute for Health Research Public Health Research programme.

Development of an investment case for obesity prevention and control: perspectives on methodological advancement and evidence

This paper opens a discussion on the main features of an investment case for obesity prevention and control, by scanning available evidence on existing approaches and by highlighting contextual considerations and evidence for Latin America and the Caribbean. We call on researchers and analysts in the field to update and broaden existing methods of economic analyses to better reflect the multisectoral nature of an investment case for obesity prevention and control. We also identify research gaps and further work required to advance methods and evidence towards investment cases throughout the Americas.

Understanding health policy to improve primary care management of obesity

NPs are ideal candidates for implementing positive health changes for obese patients. Providers have medical expertise and can promote obesity reduction strategies to their patients. Increased awareness of the influence of health policy and clinical implications for obesity management are needed.

Information sources for obesity prevention policy research: a review of systematic reviews

BACKGROUND

Systematic identification of evidence in health policy can be time-consuming and challenging. This study examines three questions pertaining to systematic reviews on obesity prevention policy, in order to identify the most efficient search methods: (1) What percentage of the primary studies selected for inclusion in the reviews originated in scholarly as opposed to gray literature? (2) How much of the primary scholarly literature in this topic area is indexed in PubMed/MEDLINE? (3) Which databases index the greatest number of primary studies not indexed in PubMed, and are these databases searched consistently across systematic reviews?

METHODS

We identified systematic reviews on obesity prevention policy and explored their search methods and citations. We determined the percentage of scholarly vs. gray literature cited, the most frequently cited journals, and whether each primary study was indexed in PubMed. We searched 21 databases for all primary study articles not indexed in PubMed to determine which database(s) indexed the highest number of these relevant articles.

RESULTS

In total, 21 systematic reviews were identified. Ten of the 21 systematic reviews reported searching gray literature, and 12 reviews ultimately included gray literature in their analyses. Scholarly articles accounted for 577 of the 649 total primary study papers. Of these, 495 (76%) were indexed in PubMed. Google Scholar retrieved the highest number of the remaining 82 non-PubMed scholarly articles, followed by Scopus and EconLit. The Journal of the American Dietetic Association was the most-cited journal.

CONCLUSIONS

Researchers can maximize search efficiency by searching a small yet targeted selection of both scholarly and gray literature resources. A highly sensitive search of PubMed and those databases that index the greatest number of relevant articles not indexed in PubMed, namely multidisciplinary and economics databases, could save considerable time and effort. When combined with a gray literature search and additional search methods, including cited reference searching and consulting with experts, this approach could help maintain broad retrieval of relevant studies while improving search efficiency. Findings also have implications for designing specialized databases for public health research.

Appetite self-regulation: Environmental and policy influences on eating behaviors

OBJECTIVE

Appetite regulation is influenced by the environment, and the environment is shaped by food-related policies. This review summarizes the environment and policy research portion of an NIH Workshop (Bethesda, MD, 2015) titled "Self-Regulation of Appetite-It's Complicated."

METHODS

In this paper, we begin by making the case for why policy is an important tool in efforts to improve nutrition, and we introduce an ecological framework that illustrates the multiple layers that influence what people eat. We describe the state of the science on how policies influence behavior in several key areas: the federal food programs, schools, child care, food and beverage pricing, marketing to youth, behavioral economics, and changing defaults. Next, we propose novel approaches for multidisciplinary prevention and intervention strategies to promote breastfeeding, and examine interactions between psychology and the environment.

RESULTS

Policy and environmental change are the most distal influences on individual-level appetite regulation, yet these strategies can reach many people at once by changing the environment in which food choices are made. We note the need for more research to understand compensatory behavior, reactance, and how to effectively change social norms.

CONCLUSIONS

To move forward, we need a more sophisticated understanding of how individual psychological and biological factors interact with the environment and policy influences.