A Sugar-Sweetened Beverage Excise Tax in California: Projected Benefits for Population Obesity and Health Equity

INTRODUCTION

Amid the successes of local sugar-sweetened beverage (SSB) taxes, interest in state-wide policies has grown. This study evaluated the cost effectiveness of a hypothetical 2-cent-per-ounce excise tax in California and its implications for population health and health equity.

METHODS

Using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model, tax impacts on health, health equity, and cost effectiveness over 10 years in California were projected, both overall and stratified by race/ethnicity and income. Expanding on previous models, differences in the effect of intake of SSBs on weight by BMI category were incorporated. Costing was performed in 2020, and analyses were conducted in 2021-2022.

RESULTS

The tax is projected to save $4.55 billion in healthcare costs, prevent 266,000 obesity cases in 2032, and gain 114,000 quality-adjusted life years. Cost-effectiveness metrics, including cost/quality-adjusted life year gained, were cost saving. Spending on SSBs was projected to decrease by $33 per adult and $26 per child overall in the first year. Reductions in obesity prevalence for Black and Hispanic Californians were 1.8 times larger than for White Californians, and reductions for adults with lowest incomes (<130% Federal Poverty Level) were 1.4 times the reduction among those with highest incomes (>350% Federal Poverty Level). The tax is projected to save $112 in obesity-related healthcare costs per $1 invested.

CONCLUSIONS

A state-wide SSB tax in California would be cost saving, lead to reductions in obesity and improvement in SSB-related health equity, and lead to overall improvements in population health. The policy would generate more than $1.6 billion in state tax revenue annually that can also be used to improve health equity.

Cost Effectiveness of Calorie Labeling at Large Fast-Food Chains Across the U.S

INTRODUCTION

Calorie labeling of standard menu items has been implemented at large restaurant chains across the U.S. since 2018. The objective of this study was to evaluate the cost effectiveness of calorie labeling at large U.S. fast-food chains.

METHODS

This study evaluated the national implementation of calorie labeling at large fast-food chains from a modified societal perspective and projected its cost effectiveness over a 10-year period (2018-2027) using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model. Using evidence from over 67 million fast-food restaurant transactions between 2015 and 2019, the impact of calorie labeling on calorie consumption and obesity incidence was projected. Benefits were estimated across all racial, ethnic, and income groups. Analyses were performed in 2022.

RESULTS

Calorie labeling is estimated to be cost saving; prevent 550,000 cases of obesity in 2027 alone (95% uncertainty interval=518,000; 586,000), including 41,500 (95% uncertainty interval=33,700; 50,800) cases of childhood obesity; and save $22.60 in healthcare costs for every $1 spent by society in implementation costs. Calorie labeling is also projected to prevent cases of obesity across all racial and ethnic groups (range between 126 and 185 cases per 100,000 people) and all income groups (range between 152 and 186 cases per 100,000 people).

CONCLUSIONS

Calorie labeling at large fast-food chains is estimated to be a cost-saving intervention to improve long-term population health. Calorie labeling is a low-cost intervention that is already implemented across the U.S. in large chain restaurants.

Cost-effectiveness of Improved WIC Food Package for Preventing Childhood Obesity

BACKGROUND AND OBJECTIVES

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) prevents food insecurity and supports nutrition for more than 3 million low-income young children. Our objectives were to determine the cost-effectiveness of changes to WIC's nutrition standards in 2009 for preventing obesity and to estimate impacts on socioeconomic and racial/ethnic inequities.

METHODS

We conducted a cost-effectiveness analysis to estimate impacts from 2010 through 2019 of the 2009 WIC food package change on obesity risk for children aged 2 to 4 years participating in WIC. Microsimulation models estimated the cases of obesity prevented in 2019 and costs per quality-adjusted-life year gained.

RESULTS

An estimated 14.0 million 2- to 4-year old US children (95% uncertainty interval (UI), 13.7-14.2 million) were reached by the updated WIC nutrition standards from 2010 through 2019. In 2019, an estimated 62 700 (95% UI, 53 900-71 100) cases of childhood obesity were prevented, entirely among children from households with low incomes, leading to improved health equity. The update was estimated to cost $10 600 per quality-adjusted-life year gained (95% UI, $9760-$11 700). If WIC had reached all eligible children, more than twice as many cases of childhood obesity would have been prevented.

CONCLUSIONS

Updates to WIC's nutrition standards for young children in 2009 were estimated to be highly cost-effective for preventing childhood obesity and contributed to reducing socioeconomic and racial/ethnic inequities in obesity prevalence. Improving nutrition policies for young children can be a sound public health investment; future research should explore how to improve access to them.

Personalized versus generic digital weight loss interventions delivered on university campuses: a 6-month cost-benefit analysis

Cost-effectiveness analyses of weight loss programs for university students can inform administrator decision-making. This study quantifies and compares the costs and cost-effectiveness of implementing two digitally-delivered weight loss interventions designed for university populations. Healthy Body Healthy U (HBHU) was a randomized controlled trial comparing TAILORED (personalized) versus TARGETED (generic) weight loss interventions adapted specifically for young adults to a CONTROL intervention. Participants (N = 459; 23.3 ± 4.4 years; mean BMI 31.2 ± 4.4 kg/m2) were recruited from two universities. Implementation costs were examined from a payer (i.e., university) perspective, comparing both the average cost effectiveness ratio (ACER) and the incremental cost effectiveness ratio (ICER) of the two interventions. Cost-effectiveness measures were calculated for changes in body weight, abdominal circumference, HDL cholesterol, systolic and diastolic blood pressure, and HbA1c. The overall 6-month implementation costs were $105.66 per person for the TAILORED intervention and $91.44 per person for the TARGETED intervention. The ACER for weight change was $107.82 for the TAILORED and $179.29 for the TARGETED interventions. The ICER comparing TAILORED with TARGETED for change in body weight was $5.05, and was even lower ($2.28) when including only those with overweight and not obesity. The ICERs for change in abdominal circumference, HDL cholesterol, systolic and diastolic blood pressure, and HbA1c were $3.49, $59.37, $1.57, $2.64, and $47.49, respectively. The TAILORED intervention was generally more cost-effective compared with the TARGETED intervention, particularly among those with overweight. Young adults with obesity may require more resource-intensive precision-based approaches.

Cost-Effectiveness of 5 Public Health Approaches to Prevent Eating Disorders

INTRODUCTION

Eating disorders cause suffering and a high risk of death. Accelerating the translation of research into implementation will require intervention cost-effectiveness estimates. The objective of this study was to estimate the cost-effectiveness of 5 public health approaches to preventing eating disorders among adolescents and young adults.

METHODS

Using data from 2001 to 2017, the authors developed a microsimulation model of a closed cohort starting at the age of 10 years and ending at 40 years. In 2021, an analysis was conducted of 5 primary and secondary prevention strategies for eating disorders: school-based screening, primary care‒based screening, school-based universal prevention, excise tax on over-the-counter diet pills, and restriction on youth purchase of over-the-counter diet pills. The authors estimated the reduction in years lived with eating disorders and the increase in quality-adjusted life-years. Intervention costs and net monetary benefit were estimated using a threshold of $100,000/quality-adjusted life year.

RESULTS

All the 5 interventions were estimated to be cost-saving compared with the current practice. Discounted per person cost savings (over the 30-year analytic time horizon) ranged from $63 (clinic screening) to $1,102 (school-based universal prevention). Excluding caregiver costs for binge eating disorder and otherwise specified feeding and eating disorders substantially reduced cost savings (e.g., from $1,102 to $149 for the school-based intervention).

CONCLUSIONS

A range of public health strategies to reduce the societal burden of eating disorders are likely cost saving. Universal prevention interventions that promote healthy nutrition, physical activity, and media use behaviors without introducing weight stigma may prevent additional negative health outcomes, such as excess weight gain.

The G-NORM Scale: Development and Validation of a Theory-Based Gender Norms Scale

Gender norms are increasingly recognized as important modifiers of health. Despite growing awareness of how gender norms affect health behavior, current gender norms scales are often missing two important theoretical components: differentiating between descriptive and injunctive norms and adding a referent group. We used a mixed-methods approach to develop and validate a novel gender norms scale that includes both theoretical components. Based on qualitative data, the theory of normative social behavior, and the theory of gender and power, we generated a pool of 28 items. We included the items in a baseline questionnaire among 3,110 women in Odisha, India as part of a cluster randomized controlled trial. We then ran exploratory factor analysis which resulted in 18 items. Using a second wave of data with the same sample, we evaluated psychometric properties using confirmatory factor analysis and structural equation modeling. The analysis resulted in two subscales with nine items each, “descriptive gender norms” and “injunctive gender norms.” Both subscales represent high internal validity with Cronbach’s alpha values of 0.81 and 0.84 and the combined scale has an alpha of 0.87. The G-NORM, gender norms scale, improves on existing measures by providing distinct descriptive and injunctive norms subscales and moving beyond individual attitudes by assessing women’s perceptions of community-level gender norms.

Excess mortality associated with elevated body weight in the USA by state and demographic subgroup: A modelling study

BACKGROUND

The obesity epidemic in the USA continues to grow nationwide. Although excess weight-related mortality has been studied in general, less is known about how it varies by demographic subgroup within the USA. In this study we estimated excess mortality associated with elevated body weight nationally and by state and subgroup.

METHODS

We developed a nationally-representative microsimulation (individual-level) model of US adults between 1999 and 2016, based on risk factor data from 6,002,012 Behavioral Risk Factor Surveillance System respondents. Prior probability distributions for hazard ratios relating body-mass index (BMI) to mortality were informed by a global pooling dataset. Individual-level mortality risks were modelled accounting for demographics, smoking history, and BMI adjusted for self-report bias. We calibrated the model to empirical all-cause mortality rates from CDC WONDER by state and subgroup, and assessed the predictive accuracy of the model using a random sample of data withheld from model fitting. We simulated counterfactual scenarios to estimate excess mortality attributable to different levels of excess weight and smoking history.

FINDINGS

We estimated that excess weight was responsible for more than 1300 excess deaths per day (nearly 500,000 per year) and a loss in life expectancy of nearly 2·4 years in 2016, contributing to higher excess mortality than smoking. Relative excess mortality rates were nearly twice as high for women compared to men in 2016 (21·9% vs 13·9%), and were higher for Black non-Hispanic adults. By state, overall excess weight-related life expectancy loss ranged from 1·75 years (95% UI 1·57-1·94) in Colorado to 3·18 years (95% UI 2·86-3·51) in Mississippi.

INTERPRETATION

Excess weight has substantial impacts on mortality in the USA, with large disparities by state and subgroup. Premature mortality will likely increase as obesity continues to rise.

FUNDING

The JPB Foundation, NIH, CDC.

Effectiveness and Cost-Benefit of an Elementary School-Based Telehealth Program

Utilization of telehealth in school-based health centers (SBHCs) is increasing rapidly during the COVID-19 pandemic. This study used a quasi-experimental design to evaluate the effect on school absences and cost-benefit of telehealth-exclusive SBHCs at 6 elementary schools from 2015-2017. The effect of telehealth on absences was estimated compared to students without telehealth using negative binomial regression controlling for absences and health suite visits in 2014 and sociodemographic characteristics. The sample included 7,164 observations from 4,203 students. Telehealth was associated with a 7.7% (p = 0.025; 95% CI: 1.0%, 14%) reduction in absences (0.60 days/year). The program cost $189,000/yr and an estimated total benefit of $384,995 (95% CI: $60,416; $687,479) and an annual net benefit of $195,873 (95% CI: -$128,706; $498,357). While this cost-benefit analysis is limited by a lack of data on total healthcare utilization, the use of telehealth-exclusive SBHCs can improve student health and attendance while delivering cost savings to society.

Limiting Television to Reduce Childhood Obesity: Cost-Effectiveness of Five Population Strategies

Objective: To quantify the potential population-wide costs, number of individuals reached, and impact on obesity of five effective interventions to reduce children's television viewing if implemented nationally. Study Design: Utilizing evidence from systematic reviews, the Childhood Obesity Intervention Cost Effectiveness Study (CHOICES) microsimulation model estimated the cost, population reach, and impact on childhood obesity from 2020 to 2030 of five hypothetical policy strategies to reduce the negative impact of children's TV exposure: (1) eliminating the tax deductibility of food and beverage advertising; (2) targeting TV reduction during home visiting programs; (3) motivational interviewing to reduce home television time at Women, Infants, and Children (WIC) clinic visits; (4) adoption of a television-reduction curriculum in child care; and (5) limiting noneducational television in licensed child care settings. Results: Eliminating the tax deductibility of food advertising could reach the most children [106 million, 95% uncertainty interval (UI): 105-107 million], prevent the most cases of obesity (78,700, 95% UI: 30,200-130,000), and save more in health care costs than it costs to implement. Strategies targeting young children in child care and WIC also cost little to implement (between $0.19 and $32.73 per child reached), and, although reaching fewer children because of the restricted age range, were estimated to prevent between 25,500 (95% UI: 4600-59,300) and 35,400 (95% UI: 13,200-62,100) cases of obesity. Home visiting to reduce television viewing had high costs and a low reach. Conclusions: Interventions to reduce television exposure across a range of settings, if implemented widely, could help prevent childhood obesity in the population at relatively low cost.

Examining intentions to take iron supplements to inform a behavioral intervention: The Reduction in Anemia through Normative Innovations (RANI) project

BACKGROUND

More than half of women of reproductive age in India have anemia. Over the last decade, India has made some progress towards reducing anemia in pregnant women, but non-pregnant women, who make up the largest sub group of people with anemia, are largely disregarded.

OBJECTIVES

The objective of this paper is to examine intentions to take iron supplements and factors associated with intentions to inform a social norms-based behavioral intervention to increase uptake of iron supplements and reduce anemia in Odisha, India.

METHODS

We collected data from 3,914 randomly sampled non-pregnant women of reproductive age in 81 villages. We conducted a survey and took hemocue (anemia level) readings from each participant. We analyzed data using linear regression models beginning with demographics and social norms and adding other factors such as self-efficacy to take iron supplements, anemia risk perception, and knowledge about anemia in a subsequent model.

RESULTS

63% of women in our sample were anemic but less than 5% knew they were anemic. Despite national guidelines that all women of reproductive age should take weekly iron supplements to prevent anemia, less than 3% of women in our sample were currently taking them. While actual use was low, intentions were rather high. On a five point Likert scale where higher numbers meant more intentions to take supplements, average intentions were above the midpoint (M = 3.48, SD = 1.27) and intentions and iron supplement use were significantly correlated (r = .10, p < .001). Both injunctive norms and collective norms were associated with intentions to take iron supplements but descriptive norms were not. Other significant factors included age, breastfeeding, knowledge, self-efficacy, and outcome expectations. The final model accounted for 74% of the variance in iron supplement intentions.

CONCLUSIONS

In this context, where the actual behavior is low but intentions to enact the behavior are high, starting an intervention with injunctive norms messaging (expectations around the behavior) and self-efficacy to enact the behavior is the step we recommend based on our results. As an intervention unfolds and iron supplement use increases, descriptive norms messaging (that people are indeed taking iron supplements) may add value.

Association of body mass index with health care expenditures in the United States by age and sex

Background

Estimates of health care costs associated with excess weight are needed to inform the development of cost-effective obesity prevention efforts. However, commonly used cost estimates are not sensitive to changes in weight across the entire body mass index (BMI) distribution as they are often based on discrete BMI categories.

Methods

We estimated continuous BMI-related health care expenditures using data from the Medical Expenditure Panel Survey (MEPS) 2011–2016 for 175,726 respondents. We adjusted BMI for self-report bias using data from the National Health and Nutrition Examination Survey (NHANES) 2011–2016, and controlled for potential confounding between BMI and medical expenditures using a two-part model. Costs are reported in $US 2019.

Results

We found a J-shaped curve of medical expenditures by BMI, with higher costs for females and the lowest expenditures occurring at a BMI of 20.5 for adult females and 23.5 for adult males. Over 30 units of BMI, each one-unit BMI increase was associated with an additional cost of $253 (95% CI $167-$347) per person. Among adults, obesity was associated with $1,861 (95% CI $1,656-$2,053) excess annual medical costs per person, accounting for $172.74 billion (95% CI $153.70-$190.61) of annual expenditures. Severe obesity was associated with excess costs of $3,097 (95% CI $2,777-$3,413) per adult. Among children, obesity was associated with $116 (95% CI $14-$201) excess costs per person and $1.32 billion (95% CI $0.16-$2.29) of medical spending, with severe obesity associated with $310 (95% CI $124-$474) excess costs per child.

Conclusions

Higher health care costs are associated with excess body weight across a broad range of ages and BMI levels, and are especially high for people with severe obesity. These findings highlight the importance of promoting a healthy weight for the entire population while also targeting efforts to prevent extreme weight gain over the life course.

Applied Methods for Estimating Transition Probabilities from Electronic Health Record Data

BACKGROUND

Electronic health record (EHR) data contain longitudinal patient information and standardized diagnostic codes. EHR data may be useful for estimating transition probabilities for state-transition models, but no guidelines exist on appropriate methods. We applied 3 potential methods to estimate transition probabilities from EHR data, using pediatric eating disorders (EDs) as a case study.

METHODS

We obtained EHR data from PEDsnet, which includes 8 US children's hospitals. Data included inpatient, outpatient, and emergency department visits for all patients with an ED. We mapped diagnoses to 3 ED health states: anorexia nervosa, bulimia nervosa, and other specified feeding or eating disorder. We estimated 1-y transition probabilities for males and females using 3 approaches: simple first-last proportions, a multistate Markov (MSM) model, and independent survival models.

RESULTS

Transition probability estimates varied widely between approaches. The first-last proportion approach estimated higher probabilities of remaining in the same health state, while the MSM and independent survival approaches estimated higher probabilities of transitioning to a different health state. All estimates differed substantially from published literature.

LIMITATIONS

As a source of health state information, EHR data are incomplete and sometimes inaccurate. EHR data were especially challenging for EDs, limiting the estimation and interpretation of transition probabilities.

CONCLUSIONS

The 3 approaches produced very different transition probability estimates. Estimates varied considerably from published literature and were rescaled and calibrated for use in a microsimulation model. Estimation of transition probabilities from EHR data may be more promising for diseases that are well documented in the EHR. Furthermore, clinicians and health systems should work to improve documentation of ED in the EHR. Further research is needed on methods for using EHR data to inform transition probabilities.

Cost-Effectiveness Of The Sugar-Sweetened Beverage Excise Tax In Mexico

An excise tax of 1 peso per liter on sugar-sweetened beverages was implemented in Mexico in 2014. We estimated the cost-effectiveness of this tax and an alternative tax scenario of 2 pesos per liter. We developed a cohort simulation model calibrated for Mexico to project the impact of the tax over ten years. The current tax is projected to prevent 239,900 cases of obesity, 39 percent of which would be among children. It could also prevent 61,340 cases of diabetes, lead to gains of 55,300 quality-adjusted life-years, and avert 5,840 disability-adjusted life-years. The tax is estimated to save $3.98 per dollar spent on its implementation. Doubling the tax to 2 pesos per liter would nearly double the cost savings and health impact. Countries with comparable conditions could benefit from implementing a similar tax.

Smoking and cessation-related attitudes among men who have sex with men in the country of Georgia

Among men who have sex with men (MSM) in low- or middle-income countries, smoking and related factors have been understudied. We examined correlates of smoking status, level, and importance and confidence regarding quitting among 608 MSM in the country of Georgia recruited in June-September, 2016 (493 without HIV via peer referral in 3 Georgian cities; 115 with HIV via the National AIDS Center). Median age was 26 years, 78.6% reported current (past 30-day) alcohol use, and 22.4% reported past-year illicit drug use. Overall, 73.8% reported current smoking; of these, 87.1% smoked daily, mean cigarettes per day (cpd) was 19.8, 64.6% smoked ≤30 min of waking, and mean quitting importance and confidence were 6.8 and 6.4 (0 = not at all to 10 = extremely), respectively. Multivariable analyses indicated that current smoking correlated with past-month alcohol and past-year illicit drug use (p's < .001). Among smokers, cpd correlated with being older and smoking within 30 min of waking; greater quitting importance (≥7) correlated with higher education and no illicit substance use; and greater quitting confidence (≥7) was associated with fewer cpd, smoking ≤30 min of waking, and regional versus capital city residence. Given these findings, addressing tobacco and other substance use among MSM in Georgia is critical.

Moving beyond individual barriers and identifying multi-level strategies to reduce anemia in Odisha India

BACKGROUND

To reduce the prevalence of anemia, the Indian government recommends daily iron and folic acid supplements (iron supplements) for pregnant women and weekly iron supplements for adolescents and all women of reproductive age. The government has distributed free iron supplements to adolescents and pregnant women for over four decades. However, initial uptake and adherence remain inadequate and non-pregnant women of reproductive age are largely ignored. The aim of this study is to examine the multilevel barriers to iron supplement use and to subsequently identify promising areas to intervene.

METHODS

We conducted a qualitative study in the state of Odisha, India. Data collection included key informant interviews, focus group discussions with women, husbands, and mothers-in-law, and direct observations in health centers, pharmacies and village health and nutrition days.

RESULTS

We found that at the individual level, participants knew that iron supplements prevent anemia but underestimated anemia prevalence and risk in their community. Participants also believed that taking too many iron supplements during pregnancy would "make your baby big" causing a painful birth and a costly cesarean section. At the interpersonal level, mothers-in-law were not supportive of their daughters-in-law taking regular iron supplements during pregnancy but husbands were more supportive. At the community level, participants reported that only pregnant women and adolescents are taking iron supplements, ignoring non-pregnant women altogether. Unequal gender norms are also an upstream barrier for non-pregnant women to prioritize their health to obtain iron supplements. At the policy level, frontline health workers distribute iron supplements to pregnant women only and do not follow up on adherence.

CONCLUSIONS

Interventions should address multiple barriers to iron supplement use along the socio-ecological model. They should also be tailored to a woman's reproductive life course stage: adolescents, pregnancy, and non-pregnant women of reproductive age because social norms and available services differ between the subpopulations.

Evaluation of a pragmatic trial of a collaborative school-based obesity prevention intervention in a low-income urban district

Broader adoption of effective school-based obesity prevention interventions is critical to the success of ongoing efforts to address the childhood obesity epidemic. School-level barriers to adopting evidence-based interventions may be overcome by empowering school-level leaders to select appropriate intervention components. We used a quasi-experimental pragmatic trial design to evaluate a tailored obesity prevention intervention in 9 schools in a mid-sized urban school district in upstate New York from fall 2013 to spring 2016. We analyzed repeated height and weight measurements from an existing district screening system on 5882 students from intervention and control schools matched using propensity score methods. We assessed diet and physical activity changes in intervention schools using surveys and direct observation. The intervention led to a change of -0.27 (p = 0.026, 95% Confidence Interval (CI): -0.51, -0.03) and -0.28 (p = 0.031, 95% CI: -0.54, -0.03) BMI units in spring 2014 and fall 2014, respectively. There were no significant differences between intervention and control from spring 2015 to spring 2016. Despite the lack of sustained effects on BMI, we demonstrated the potential of supporting school leaders in a low-income district to implement supportive policy and practice changes and of using an existing BMI screening system to reduce the burden of health promotion evaluation.

Projected U.S. State-Level Prevalence of Adult Obesity and Severe Obesity

BACKGROUND

Although the national obesity epidemic has been well documented, less is known about obesity at the U.S. state level. Current estimates are based on body measures reported by persons themselves that underestimate the prevalence of obesity, especially severe obesity.

METHODS

We developed methods to correct for self-reporting bias and to estimate state-specific and demographic subgroup-specific trends and projections of the prevalence of categories of body-mass index (BMI). BMI data reported by 6,264,226 adults (18 years of age or older) who participated in the Behavioral Risk Factor Surveillance System Survey (1993-1994 and 1999-2016) were obtained and corrected for quantile-specific self-reporting bias with the use of measured data from 57,131 adults who participated in the National Health and Nutrition Examination Survey. We fitted multinomial regressions for each state and subgroup to estimate the prevalence of four BMI categories from 1990 through 2030: underweight or normal weight (BMI [the weight in kilograms divided by the square of the height in meters], <25), overweight (25 to <30), moderate obesity (30 to <35), and severe obesity (≥35). We evaluated the accuracy of our approach using data from 1990 through 2010 to predict 2016 outcomes.

RESULTS

The findings from our approach suggest with high predictive accuracy that by 2030 nearly 1 in 2 adults will have obesity (48.9%; 95% confidence interval [CI], 47.7 to 50.1), and the prevalence will be higher than 50% in 29 states and not below 35% in any state. Nearly 1 in 4 adults is projected to have severe obesity by 2030 (24.2%; 95% CI, 22.9 to 25.5), and the prevalence will be higher than 25% in 25 states. We predict that, nationally, severe obesity is likely to become the most common BMI category among women (27.6%; 95% CI, 26.1 to 29.2), non-Hispanic black adults (31.7%; 95% CI, 29.9 to 33.4), and low-income adults (31.7%; 95% CI, 30.2 to 33.2).

CONCLUSIONS

Our analysis indicates that the prevalence of adult obesity and severe obesity will continue to increase nationwide, with large disparities across states and demographic subgroups. (Funded by the JPB Foundation.).

Cost-Effectiveness of Water Promotion Strategies in Schools for Preventing Childhood Obesity and Increasing Water Intake

OBJECTIVE

This study aimed to estimate the cost-effectiveness and impact on childhood obesity of installation of chilled water dispensers ("water jets") on school lunch lines and to compare water jets' cost, reach, and impact on water consumption with three additional strategies.

METHODS

The Childhood Obesity Intervention Cost Effectiveness Study(CHOICES) microsimulation model estimated the cost-effectiveness of water jets on US childhood obesity cases prevented in 2025. Also estimated were the cost, number of children reached, and impact on water consumption of the installation of water jets and three other strategies.

RESULTS

Installing water jets on school lunch lines was projected to reach 29.6 million children (95% uncertainty interval [UI]: 29.4 million-29.8 million), cost $4.25 (95% UI: $2.74-$5.69) per child, prevent 179,550 cases of childhood obesity in 2025 (95% UI: 101,970-257,870), and save $0.31 in health care costs per dollar invested (95% UI: $0.15-$0.55). In the secondary analysis, installing cup dispensers next to existing water fountains was the least costly but also had the lowest population reach.

CONCLUSIONS

Installating water jet dispensers on school lunch lines could also save almost half of the dollars needed for implementation via a reduction in obesity-related health care costs. School-based interventions to promote drinking water may be relatively inexpensive strategies for improving child health.

Cost-Effectiveness Analysis and Stakeholder Evaluation of 2 Obesity Prevention Policies in Maine, US

OBJECTIVE

To evaluate the potential cost-effectiveness of and stakeholder perspectives on a sugar-sweetened beverage (SSB) excise tax and a Supplemental Nutrition Assistance Program (SNAP) policy that would not allow SSB purchases in Maine, US.

DESIGN

A cost-effectiveness simulation model combined with stakeholder interviews.

SETTING

Maine, US.

PARTICIPANTS

Microsimulation of the Maine population in 2015 and interviews with stakeholders (n = 14). Study conducted from 2013 to 2017.

MAIN OUTCOME MEASURES

Health care cost savings, net costs, and quality-adjusted life-years (QALYs) from 2017 to 2027. Stakeholder positions on policies. Retail SSB cost and implementation cost data were collected.

ANALYSIS

Childhood Obesity Intervention Cost-Effectiveness Study project microsimulation model with uncertainty analysis to estimate cost-effectiveness. Thematic stakeholder interview coding.

RESULTS

Over 10 years, the SSB and SNAP policies were projected to reduce health care costs by $78.3 million (95% uncertainty interval [UI], $31.7 million-$185 million) and $15.3 million (95% UI, $8.32 million-$23.9 million), respectively. The SSB and SNAP policies were projected to save 3,560 QALYs (95% UI, 1,447-8,361) and 749 QALYs (95% UI, 415-1,168), respectively. Stakeholders were more supportive of SSB taxes than the SNAP policy because of equity concerns associated with the SNAP policy.

CONCLUSIONS AND IMPLICATIONS

Cost-effectiveness analysis provided evidence of potential health improvement and cost savings to state-level stakeholders weighing broader implementation considerations.

Estimation of Eating Disorders Prevalence by Age and Associations With Mortality in a Simulated Nationally Representative US Cohort

IMPORTANCE

Eating disorders (EDs) are common psychiatric disorders associated with high mortality. However, data on ED disease dynamics and treatment coverage are sparse.

OBJECTIVES

To model the individual-level disease dynamics of ED from birth to age 40 years and to estimate the association of increased treatment coverage with ED-related mortality.

DESIGN, SETTING, AND PARTICIPANTS

In this decision analytical model study, an individual-level Markov state transition model was empirically calibrated in April 2019 using a Bayesian approach to synthesize available clinical and epidemiologic ED data. The simulation model was calibrated to nationally representative US survey data from 2007 and 2011. A virtual cohort of 100 000 individuals (50 000 [50%] male) was modeled from birth to age 40 years for 4 ED diagnoses: anorexia nervosa, bulimia nervosa, binge eating disorder, and other specified feeding and eating disorders.

EXPOSURES

Age-specific ED incidence and mortality rates and background (all-cause) mortality.

MAIN OUTCOMES AND MEASURES

The main outcomes were age-specific 12-month and lifetime ED prevalence and number of deaths per 100 000 general population individuals by age 40 years. The mean and 95% uncertainty intervals (UIs) of 1000 simulations, accounting for stochastic and parameter uncertainty, are reported.

RESULTS

The highest estimated mean annual prevalence of ED occurred at approximately age 21 years for both male individuals (7.4%; 95% UI, 3.5%-11.5%) and female individuals (10.3%; 95% UI, 7.0%-14.2%), with lifetime mean prevalence estimates increasing to 14.3% (95% UI, 9.7%-19.0%) for male individuals and 19.7% (95% UI, 15.8%-23.9%) for female individuals by age 40 years. Ninety-five percent of first-time cases occurred by age 25 years. Current treatment coverage averts an estimated mean of 41.7 deaths per 100 000 people (95% UI, 13.0-82.0 deaths per 100 000 people) by age 40 years, whereas increasing treatment coverage for all patients with ED could avert an estimated mean of 70.5 deaths per 100 000 people by age 40 years (95% UI, 26.0-143.0 deaths per 100 000 people).

CONCLUSIONS AND RELEVANCE

In this simulation modeling study, the estimated lifetime prevalence of ED was high, with approximately 1 in 7 male and 1 in 5 female individuals having an ED by age 40 years. The initial onset of EDs was highly concentrated during adolescence and young adulthood, suggesting that this is a critical period for prevention efforts. However, the high estimated prevalence of recurring ED later in life highlights the importance of identification and treatment of ED at older ages as well. These findings suggest that increasing treatment coverage could substantially reduce ED-related mortality.

WIC Food Package Changes: Trends in Childhood Obesity Prevalence

OBJECTIVES

To evaluate the association of the 2009 changes to the US Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package and childhood obesity trends. We hypothesized that the food package change reduced obesity among children participating in WIC, a population that has been especially vulnerable to the childhood obesity epidemic.

METHODS

We used an interrupted time-series design with repeated cross-sectional measurements of state-specific obesity prevalence among WIC-participating 2- to 4-year-old children from 2000 to 2014. We used multilevel linear regression models to estimate the trend in obesity prevalence for states before the WIC package revision and to test whether the trend in obesity prevalence changed after the 2009 WIC package revision, adjusting for changes in demographics. In a secondary analysis, we adjusted for changes in macrosomia and high prepregnancy BMI.

RESULTS

Before the 2009 WIC food package change, the prevalence of obesity across states among 2- to 4-year-old WIC participants was increasing by 0.23 percentage points annually (95% confidence interval: 0.17 to 0.29; P < .001). After 2009, the trend was reversed (-0.34 percentage points per year; 95% confidence interval: -0.42 to -0.25; P < .001). Changes in sociodemographic and other obesity risk factors did not account for this change in the trend in obesity prevalence.

CONCLUSIONS

The 2009 WIC food package change may have helped to reverse the rapid increase in obesity prevalence among WIC participants observed before the food package change.

Systematic Review of School Telehealth Evaluations

School telehealth is an alternative delivery model to increase student health-care access with minimal evaluation to aid decision makers in the adoption or expansion of programs. This systematic review assesses school-based telehealth programs using a dissemination and implementation (D&I) framework to inform practitioners and decision makers of the value of school telehealth. We assessed findings from 20 studies on telehealth published between January 2006 and June 2018 and summarized program evaluation on a range of D&I constructs. The sample population included children in school- or center-based early childhood education under age 22 and included parents, providers, and school personnel across urban and suburban locations. There is some evidence that school telehealth can reduce emergency department visits and improve health status for children with chronic and acute illnesses. Future research should report on barriers and facilitators of implementation of programs, including costs related to application of telehealth services and utilization rates.

Enhancing Educator Engagement in School Mental Health Care Through Digital Simulation Professional Development

BACKGROUND

Despite the critical role of educators as gatekeepers for school mental health services, they receive limited training to support student mental health. We report findings from a trial of an online mental health role-play simulation for elementary school teachers on changes in attitudes and self-reported helping behaviors for students experiencing psychological distress.

METHODS

We randomly assigned 18,896 elementary school teachers to wait-list control or intervention conditions in which they received the 45- to 90-minute online role-play simulation. We administered a version of the validated Gatekeeper Behavior Scale at baseline and postintervention, which measures attitudinal dimensions shown to predict teacher helping behavior change. Self-reported helping behaviors were collected at baseline and 3-month follow-up. Outcomes were compared between the intervention follow-up and control group baseline measures.

RESULTS

The intervention group posttraining scores were significantly higher (p < .001) than the control group for all the preparedness, likelihood, and self-efficacy Gatekeeper Behavior subscales. All 5 helping behaviors were significantly higher among the intervention group at follow-up compared to the control group at baseline.

CONCLUSIONS

We found that a brief online role-play simulation was an effective strategy for improving teacher attitudes and behaviors needed to perform a positive mental health gatekeeper role in schools.

Simulation of Growth Trajectories of Childhood Obesity into Adulthood

BACKGROUND

Although the current obesity epidemic has been well documented in children and adults, less is known about long-term risks of adult obesity for a given child at his or her present age and weight. We developed a simulation model to estimate the risk of adult obesity at the age of 35 years for the current population of children in the United States.

METHODS

We pooled height and weight data from five nationally representative longitudinal studies totaling 176,720 observations from 41,567 children and adults. We simulated growth trajectories across the life course and adjusted for secular trends. We created 1000 virtual populations of 1 million children through the age of 19 years that were representative of the 2016 population of the United States and projected their trajectories in height and weight up to the age of 35 years. Severe obesity was defined as a body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) of 35 or higher in adults and 120% or more of the 95th percentile in children.

RESULTS

Given the current level of childhood obesity, the models predicted that a majority of today's children (57.3%; 95% uncertainly interval [UI], 55.2 to 60.0) will be obese at the age of 35 years, and roughly half of the projected prevalence will occur during childhood. Our simulations indicated that the relative risk of adult obesity increased with age and BMI, from 1.17 (95% UI, 1.09 to 1.29) for overweight 2-year-olds to 3.10 (95% UI, 2.43 to 3.65) for 19-year-olds with severe obesity. For children with severe obesity, the chance they will no longer be obese at the age of 35 years fell from 21.0% (95% UI, 7.3 to 47.3) at the age of 2 years to 6.1% (95% UI, 2.1 to 9.9) at the age of 19 years.

CONCLUSIONS

On the basis of our simulation models, childhood obesity and overweight will continue to be a major health problem in the United States. Early development of obesity predicted obesity in adulthood, especially for children who were severely obese. (Funded by the JPB Foundation and others.).

Cost-Effectiveness of a Clinical Childhood Obesity Intervention

OBJECTIVES

To estimate the cost-effectiveness and population impact of the national implementation of the Study of Technology to Accelerate Research (STAR) intervention for childhood obesity.

METHODS

In the STAR cluster-randomized trial, 6- to 12-year-old children with obesity seen at pediatric practices with electronic health record (EHR)-based decision support for primary care providers and self-guided behavior-change support for parents had significantly smaller increases in BMI than children who received usual care. We used a microsimulation model of a national implementation of STAR from 2015 to 2025 among all pediatric primary care providers in the United States with fully functional EHRs to estimate cost, impact on obesity prevalence, and cost-effectiveness.

RESULTS

The expected population reach of a 10-year national implementation is ∼2 million children, with intervention costs of $119 per child and $237 per BMI unit reduced. At 10 years, assuming maintenance of effect, the intervention is expected to avert 43 000 cases and 226 000 life-years with obesity at a net cost of $4085 per case and $774 per life-year with obesity averted. Limiting implementation to large practices and using higher estimates of EHR adoption improved both cost-effectiveness and reach, whereas decreasing the maintenance of the intervention's effect worsened the former.

CONCLUSIONS

A childhood obesity intervention with electronic decision support for clinicians and self-guided behavior-change support for parents may be more cost-effective than previous clinical interventions. Effective and efficient interventions that target children with obesity are necessary and could work in synergy with population-level prevention strategies to accelerate progress in reducing obesity prevalence.

Racial/Ethnic and Socioeconomic Disparities in Hydration Status Among US Adults and the Role of Tap Water and Other Beverage Intake

OBJECTIVES

To evaluate whether differences in tap water and other beverage intake explain differences in inadequate hydration among US adults by race/ethnicity and income.

METHODS

We estimated the prevalence of inadequate hydration (urine osmolality ≥ 800 mOsm/kg) by race/ethnicity and income of 8258 participants aged 20 to 74 years in the 2009 to 2012 National Health and Nutrition Examination Survey. Using multivariable regression models, we estimated associations between demographic variables, tap water intake, and inadequate hydration.

RESULTS

The prevalence of inadequate hydration among US adults was 29.5%. Non-Hispanic Blacks (adjusted odds ratio [AOR] = 1.44; 95% confidence interval [CI] = 1.17, 1.76) and Hispanics (AOR = 1.42; 95% CI = 1.21, 1.67) had a higher risk of inadequate hydration than did non-Hispanic Whites. Lower-income adults had a higher risk of inadequate hydration than did higher-income adults (AOR = 1.23; 95% CI = 1.04, 1.45). Differences in tap water intake partially attenuated racial/ethnic differences in hydration status. Differences in total beverage and other fluid intake further attenuated sociodemographic disparities.

CONCLUSIONS

Racial/ethnic and socioeconomic disparities in inadequate hydration among US adults are related to differences in tap water and other beverage intake. Policy action is needed to ensure equitable access to healthy beverages.

Using cost-effectiveness analysis to prioritize policy and programmatic approaches to physical activity promotion and obesity prevention in childhood

Participation in recommended levels of physical activity promotes a healthy body weight and reduced chronic disease risk. To inform investment in prevention initiatives, we simulate the national implementation, impact on physical activity and childhood obesity and associated cost-effectiveness (versus the status quo) of six recommended strategies that can be applied throughout childhood to increase physical activity in US school, afterschool and childcare settings. In 2016, the Childhood Obesity Intervention Cost Effectiveness Study (CHOICES) systematic review process identified six interventions for study. A microsimulation model estimated intervention outcomes 2015-2025 including changes in mean MET-hours/day, intervention reach and cost per person, cost per MET-hour change, ten-year net costs to society and cases of childhood obesity prevented. First year reach of the interventions ranged from 90,000 youth attending a Healthy Afterschool Program to 31.3 million youth reached by Active School Day policies. Mean MET-hour/day/person increases ranged from 0.05 MET-hour/day/person for Active PE and Healthy Afterschool to 1.29 MET-hour/day/person for the implementation of New Afterschool Programs. Cost per MET-hour change ranged from cost saving to $3.14. Approximately 2500 to 110,000 cases of children with obesity could be prevented depending on the intervention implemented. All of the six interventions are estimated to increase physical activity levels among children and adolescents in the US population and prevent cases of childhood obesity. Results do not include other impacts of increased physical activity, including cognitive and behavioral effects. Decision-makers can use these methods to inform prioritization of physical activity promotion and obesity prevention on policy agendas.

Severe Obesity In Adults Cost State Medicaid Programs Nearly $8 Billion In 2013

Efforts to expand Medicaid while controlling spending must be informed by a deeper understanding of the extent to which the high medical costs associated with severe obesity (having a body mass index of [Formula: see text] or higher) determine spending at the state level. Our analysis of population-representative data indicates that in 2013, severe obesity cost the nation approximately $69 billion, which accounted for 60 percent of total obesity-related costs. Approximately 11 percent of the cost of severe obesity was paid for by Medicaid, 30 percent by Medicare and other federal health programs, 27 percent by private health plans, and 30 percent out of pocket. Overall, severe obesity cost state Medicaid programs almost $8 billion a year, ranging from $5 million in Wyoming to $1.3 billion in California. These costs are likely to increase following Medicaid expansion and enhanced coverage of weight loss therapies in the form of nutrition consultation, drug therapy, and bariatric surgery. Ensuring and expanding Medicaid-eligible populations' access to cost-effective treatment for severe obesity should be part of each state's strategy to mitigate rising obesity-related health care costs.

Three Interventions That Reduce Childhood Obesity Are Projected To Save More Than They Cost To Implement

Policy makers seeking to reduce childhood obesity must prioritize investment in treatment and primary prevention. We estimated the cost-effectiveness of seven interventions high on the obesity policy agenda: a sugar-sweetened beverage excise tax; elimination of the tax subsidy for advertising unhealthy food to children; restaurant menu calorie labeling; nutrition standards for school meals; nutrition standards for all other food and beverages sold in schools; improved early care and education; and increased access to adolescent bariatric surgery. We used systematic reviews and a microsimulation model of national implementation of the interventions over the period 2015-25 to estimate their impact on obesity prevalence and their cost-effectiveness for reducing the body mass index of individuals. In our model, three of the seven interventions--excise tax, elimination of the tax deduction, and nutrition standards for food and beverages sold in schools outside of meals--saved more in health care costs than they cost to implement. Each of the three interventions prevented 129,000-576,000 cases of childhood obesity in 2025. Adolescent bariatric surgery had a negligible impact on obesity prevalence. Our results highlight the importance of primary prevention for policy makers aiming to reduce childhood obesity.

Public Perception of Quality and Support for Required Access to Drinking Water in Schools and Parks

PURPOSE

We assessed public support for required water access in schools and parks and perceived safety and taste of water in these settings to inform efforts to increase access to and consumption of tap water.

DESIGN

Cross-sectional survey of the US public collected from August to November 2011.

SETTING

Random digit-dialed telephone survey.

PARTICIPANTS

Participants (n = 1218) aged 17 and older from 1055 US counties in 46 states.

MEASURES

Perceived safety and taste of water in schools and parks as well as support for required access to water in these settings.

ANALYSIS

Survey-adjusted perceived safety and taste as well as support for required access were estimated.

RESULTS

There was broad support for required access to water throughout the day in schools (96%) and parks (89%). Few participants believed water was unsafe in schools (10%) or parks (18%).

CONCLUSION

This study provides evidence of public support for efforts to increase access to drinking water in schools and parks and documents overall high levels of perceived taste and safety of water provided in these settings.

US States' Childhood Obesity Surveillance Practices and Recommendations for Improving Them, 2014-2015

Introduction

Routine collection, analysis, and reporting of data on child height, weight, and body mass index (BMI), particularly at the state and local levels, are needed to monitor the childhood obesity epidemic, plan intervention strategies, and evaluate the impact of interventions. Child BMI surveillance systems operated by the US government do not provide state or local data on children across a range of ages. The objective of this study was to describe the extent to which state governments conduct child BMI surveillance.

Methods

From August through December 2014, we conducted a structured telephone survey with state government administrators to learn about state surveillance of child BMI. We also searched websites of state health and education agencies for information about state surveillance.

Results

State agency administrators in 48 states and Washington, DC, completed telephone interviews (96% response rate). Based on our interviews and Internet research, we determined that 14 states collect child BMI data in a manner consistent with standard definitions of public health surveillance.

Conclusion

The absence of child BMI surveillance systems in most states limits the ability of public health practitioners and policymakers to develop and evaluate responses to the childhood obesity epidemic. Greater investment in surveillance is needed to identify the most effective and cost-effective childhood obesity interventions.

State-level estimates of childhood obesity prevalence in the United States corrected for report bias

BACKGROUND/OBJECTIVES

State-specific obesity prevalence data are critical to public health efforts to address the childhood obesity epidemic. However, few states administer objectively measured body mass index (BMI) surveillance programs. This study reports state-specific childhood obesity prevalence by age and sex correcting for parent-reported child height and weight bias.

SUBJECTS/METHODS

As part of the Childhood Obesity Intervention Cost Effectiveness Study (CHOICES), we developed childhood obesity prevalence estimates for states for the period 2005-2010 using data from the 2010 US Census and American Community Survey (ACS), 2003-2004 and 2007-2008 National Survey of Children's Health (NSCH) (n=133 213), and 2005-2010 National Health and Nutrition Examination Surveys (NHANES) (n=9377; ages 2-17). Measured height and weight data from NHANES were used to correct parent-report bias in NSCH using a non-parametric statistical matching algorithm. Model estimates were validated against surveillance data from five states (AR, FL, MA, PA and TN) that conduct censuses of children across a range of grades.

RESULTS

Parent-reported height and weight resulted in the largest overestimation of childhood obesity in males ages 2-5 years (NSCH: 42.36% vs NHANES: 11.44%). The CHOICES model estimates for this group (12.81%) and for all age and sex categories were not statistically different from NHANES. Our modeled obesity prevalence aligned closely with measured data from five validation states, with a 0.64 percentage point mean difference (range: 0.23-1.39) and a high correlation coefficient (r=0.96, P=0.009). Estimated state-specific childhood obesity prevalence ranged from 11.0 to 20.4%.

CONCLUSION

Uncorrected estimates of childhood obesity prevalence from NSCH vary widely from measured national data, from a 278% overestimate among males aged 2-5 years to a 44% underestimate among females aged 14-17 years. This study demonstrates the validity of the CHOICES matching methods to correct the bias of parent-reported BMI data and highlights the need for public release of more recent data from the 2011 to 2012 NSCH.

Redrawing the US Obesity Landscape: Bias-Corrected Estimates of State-Specific Adult Obesity Prevalence

BACKGROUND

State-level estimates from the Centers for Disease Control and Prevention (CDC) underestimate the obesity epidemic because they use self-reported height and weight. We describe a novel bias-correction method and produce corrected state-level estimates of obesity and severe obesity.

METHODS

Using non-parametric statistical matching, we adjusted self-reported data from the Behavioral Risk Factor Surveillance System (BRFSS) 2013 (n = 386,795) using measured data from the National Health and Nutrition Examination Survey (NHANES) (n = 16,924). We validated our national estimates against NHANES and estimated bias-corrected state-specific prevalence of obesity (BMI≥30) and severe obesity (BMI≥35). We compared these results with previous adjustment methods.

RESULTS

Compared to NHANES, self-reported BRFSS data underestimated national prevalence of obesity by 16% (28.67% vs 34.01%), and severe obesity by 23% (11.03% vs 14.26%). Our method was not significantly different from NHANES for obesity or severe obesity, while previous methods underestimated both. Only four states had a corrected obesity prevalence below 30%, with four exceeding 40%-in contrast, most states were below 30% in CDC maps.

CONCLUSIONS

Twelve million adults with obesity (including 6.7 million with severe obesity) were misclassified by CDC state-level estimates. Previous bias-correction methods also resulted in underestimates. Accurate state-level estimates are necessary to plan for resources to address the obesity epidemic.

BMI and Healthcare Cost Impact of Eliminating Tax Subsidy for Advertising Unhealthy Food to Youth

INTRODUCTION

Food and beverage TV advertising contributes to childhood obesity. The current tax treatment of advertising as an ordinary business expense in the U.S. subsidizes marketing of nutritionally poor foods and beverages to children. This study models the effect of a national intervention that eliminates the tax subsidy of advertising nutritionally poor foods and beverages on TV to children aged 2-19 years.

METHODS

We adapted and modified the Assessing Cost Effectiveness framework and methods to create the Childhood Obesity Intervention Cost Effectiveness Study model to simulate the impact of the intervention over the 2015-2025 period for the U.S. population, including short-term effects on BMI and 10-year healthcare expenditures. We simulated uncertainty intervals (UIs) using probabilistic sensitivity analysis and discounted outcomes at 3% annually. Data were analyzed in 2014.

RESULTS

We estimated the intervention would reduce an aggregate 2.13 million (95% UI=0.83 million, 3.52 million) BMI units in the population and would cost $1.16 per BMI unit reduced (95% UI=$0.51, $2.63). From 2015 to 2025, the intervention would result in $352 million (95% UI=$138 million, $581 million) in healthcare cost savings and gain 4,538 (95% UI=1,752, 7,489) quality-adjusted life-years.

CONCLUSIONS

Eliminating the tax subsidy of TV advertising costs for nutritionally poor foods and beverages advertised to children and adolescents would likely be a cost-saving strategy to reduce childhood obesity and related healthcare expenditures.

Modeling the Cost Effectiveness of Child Care Policy Changes in the U.S

INTRODUCTION

Child care facilities influence diet and physical activity, making them ideal obesity prevention settings. The purpose of this study is to quantify the health and economic impacts of a multi-component regulatory obesity policy intervention in licensed U.S. child care facilities.

METHODS

Two-year costs and BMI changes resulting from changes in beverage, physical activity, and screen time regulations affecting a cohort of up to 6.5 million preschool-aged children attending child care facilities were estimated in 2014 using published data. A Markov cohort model simulated the intervention's impact on changes in the U.S. population from 2015 to 2025, including short-term BMI effects and 10-year healthcare expenditures. Future outcomes were discounted at 3% annually. Probabilistic sensitivity analyses simulated 95% uncertainty intervals (UIs) around outcomes.

RESULTS

Regulatory changes would lead children to watch less TV, get more minutes of moderate and vigorous physical activity, and consume fewer sugar-sweetened beverages. Within the 6.5 million eligible population, national implementation could reach 3.69 million children, cost $4.82 million in the first year, and result in 0.0186 fewer BMI units (95% UI=0.00592 kg/m(2), 0.0434 kg/m(2)) per eligible child at a cost of $57.80 per BMI unit avoided. Over 10 years, these effects would result in net healthcare cost savings of $51.6 (95% UI=$14.2, $134) million. The intervention is 94.7% likely to be cost saving by 2025.

CONCLUSIONS

Changing child care regulations could have a small but meaningful impact on short-term BMI at low cost. If effects are maintained for 10 years, obesity-related healthcare cost savings are likely.

Cost Effectiveness of a Sugar-Sweetened Beverage Excise Tax in the U.S

INTRODUCTION

Reducing sugar-sweetened beverage consumption through taxation is a promising public health response to the obesity epidemic in the U.S. This study quantifies the expected health and economic benefits of a national sugar-sweetened beverage excise tax of $0.01/ounce over 10 years.

METHODS

A cohort model was used to simulate the impact of the tax on BMI. Assuming ongoing implementation and effect maintenance, quality-adjusted life-years gained and disability-adjusted life-years and healthcare costs averted were estimated over the 2015-2025 period for the 2015 U.S.

POPULATION

Costs and health gains were discounted at 3% annually. Data were analyzed in 2014.

RESULTS

Implementing the tax nationally would cost $51 million in the first year. The tax would reduce sugar-sweetened beverage consumption by 20% and mean BMI by 0.16 (95% uncertainty interval [UI]=0.06, 0.37) units among youth and 0.08 (95% UI=0.03, 0.20) units among adults in the second year for a cost of $3.16 (95% UI=$1.24, $8.14) per BMI unit reduced. From 2015 to 2025, the policy would avert 101,000 disability-adjusted life-years (95% UI=34,800, 249,000); gain 871,000 quality-adjusted life-years (95% UI=342,000, 2,030,000); and result in $23.6 billion (95% UI=$9.33 billion, $54.9 billion) in healthcare cost savings. The tax would generate $12.5 billion in annual revenue (95% UI=$8.92, billion, $14.1 billion).

CONCLUSIONS

The proposed tax could substantially reduce BMI and healthcare expenditures and increase healthy life expectancy. Concerns regarding the potentially regressive tax may be addressed by reduced obesity disparities and progressive earmarking of tax revenue for health promotion.

Cost Effectiveness of Childhood Obesity Interventions: Evidence and Methods for CHOICES

INTRODUCTION

The childhood obesity epidemic continues in the U.S., and fiscal crises are leading policymakers to ask not only whether an intervention works but also whether it offers value for money. However, cost-effectiveness analyses have been limited. This paper discusses methods and outcomes of four childhood obesity interventions: (1) sugar-sweetened beverage excise tax (SSB); (2) eliminating tax subsidy of TV advertising to children (TV AD); (3) early care and education policy change (ECE); and (4) active physical education (Active PE).

METHODS

Cost-effectiveness models of nationwide implementation of interventions were estimated for a simulated cohort representative of the 2015 U.S. population over 10 years (2015-2025). A societal perspective was used; future outcomes were discounted at 3%. Data were analyzed in 2014. Effectiveness, implementation, and equity issues were reviewed.

RESULTS

Population reach varied widely, and cost per BMI change ranged from $1.16 (TV AD) to $401 (Active PE). At 10 years, assuming maintenance of the intervention effect, three interventions would save net costs, with SSB and TV AD saving $55 and $38 for every dollar spent. The SSB intervention would avert disability-adjusted life years, and both SSB and TV AD would increase quality-adjusted life years. Both SSB ($12.5 billion) and TV AD ($80 million) would produce yearly tax revenue.

CONCLUSIONS

The cost effectiveness of these preventive interventions is greater than that seen for published clinical interventions to treat obesity. Cost-effectiveness evaluations of childhood obesity interventions can provide decision makers with information demonstrating best value for the money.

Prevalence of Inadequate Hydration Among US Children and Disparities by Gender and Race/Ethnicity: National Health and Nutrition Examination Survey, 2009-2012

OBJECTIVES

We evaluated the hydration status of US children and adolescents.

METHODS

The sample included 4134 participants aged 6 to 19 years in the National Health and Nutrition Examination Survey from 2009 to 2012. We calculated mean urine osmolality and the proportion with inadequate hydration (urine osmolality > 800 mOsm/kg). We calculated multivariable regression models to estimate the associations between demographic factors, beverage intake, and hydration status.

RESULTS

The prevalence of inadequate hydration was 54.5%. Significantly higher urine osmolality was observed among boys (+92.0 mOsm/kg; 95% confidence interval [CI] = 69.5, 114.6), non-Hispanic Blacks (+67.6 mOsm/kg; 95% CI = 31.5, 103.6), and younger children (+28.5 mOsm/kg; 95% CI = 8.1, 48.9) compared with girls, Whites, and older children, respectively. Boys (OR = 1.76; 95% CI = 1.49, 2.07) and non-Hispanic Blacks (odds ratio [OR] = 1.34; 95% CI = 1.04, 1.74) were also at significantly higher risk for inadequate hydration. An 8-fluid-ounce daily increase in water intake was associated with a significantly lower risk of inadequate hydration (OR = 0.96; 95% CI = 0.93, 0.98).

CONCLUSIONS

Future research should explore drivers of gender and racial/ethnic disparities and solutions for improving hydration status.

Support for Policies to Improve the Nutritional Impact of the Supplemental Nutrition Assistance Program in California

The Supplemental Nutrition Assistance Program (SNAP) provides a vital buffer against hunger and poverty for 47.6 million Americans. Using 2013 California Dietary Practices Survey data, we assessed support for policies to strengthen the nutritional influence of SNAP. Among SNAP participants, support ranged from 74% to 93% for providing monetary incentives for fruits and vegetables, restricting purchases of sugary beverages, and providing more total benefits. Nonparticipants expressed similar levels of support. These approaches may alleviate the burden of diet-related disease in low-income populations.

Systematic review and meta-analysis of the impact of restaurant menu calorie labeling

We conducted a systematic review and meta-analysis evaluating the relationship between menu calorie labeling and calories ordered or purchased in the PubMed, Web of Science, PolicyFile, and PAIS International databases through October 2013. Among 19 studies, menu calorie labeling was associated with a -18.13 kilocalorie reduction ordered per meal with significant heterogeneity across studies (95% confidence interval = -33.56, -2.70; P = .021; I(2) = 61.0%). However, among 6 controlled studies in restaurant settings, labeling was associated with a nonsignificant -7.63 kilocalorie reduction (95% confidence interval = -21.02, 5.76; P = .264; I(2) = 9.8%). Although current evidence does not support a significant impact on calories ordered, menu calorie labeling is a relatively low-cost education strategy that may lead consumers to purchase slightly fewer calories. These findings are limited by significant heterogeneity among nonrestaurant studies and few studies conducted in restaurant settings.

Juice and water intake in infancy and later beverage intake and adiposity: could juice be a gateway drink?

OBJECTIVES

To examine the tracking and significance of beverage consumption in infancy and childhood.

METHODS

Among 1163 children in Project Viva, we examined associations of fruit juice and water intake at 1 year (0 oz, 1-7 oz [small], 8-15 oz [medium], and ≥16 oz [large]) with juice and sugar-sweetened beverage (SSB) intake and BMI z-score during early (median 3.1 years) and mid-childhood (median 7.7 years).

RESULTS

In covariate adjusted models, juice intake at 1 year was associated with greater juice and SSB intake during early and mid-childhood and also greater adiposity. Children who drank medium and large amounts of juice at 1 year had higher BMI z-scores during both early (medium: β = 0.16 [95% CI = 0.01-0.32]; large: β = 0.28 [95% CI = 0.01-0.56]) and mid-childhood (medium: β = 0.23 [95% CI = 0.07-0.39]; large: β = 0.36 [95% CI = 0.08-0.64]). After covariate adjustment, associations between water intake at 1 year and beverage intake and adiposity later in childhood were null.

CONCLUSIONS

Higher juice intake at 1 year was associated with higher juice intake, SSB intake, and BMI z-score during early and mid-childhood. Assessing juice intake during infancy could provide clinicians with important data regarding future unhealthy beverage habits and excess adiposity during childhood.

Distinct magnetic phase transition at the surface of an antiferromagnet

In the majority of magnetic systems the surface is required to order at the same temperature as the bulk. In the present Letter, we report a distinct and unexpected surface magnetic phase transition at a lower temperature than the Néel temperature. Employing grazing incidence x-ray resonant magnetic scattering, we have observed the near-surface behavior of uranium dioxide. UO2 is a noncollinear, triple-q, antiferromagnet with the U ions on a face-centered cubic lattice. Theoretical investigations establish that at the surface the energy increase-due to the lost bonds-is reduced when the spins near the surface rotate, gradually losing their component normal to the surface. At the surface the lowest-energy spin configuration has a double-q (planar) structure. With increasing temperature, thermal fluctuations saturate the in-plane crystal field anisotropy at the surface, leading to soft excitations that have ferromagnetic XY character and are decoupled from the bulk. The structure factor of a finite two-dimensional XY model fits the experimental data well for several orders of magnitude of the scattered intensity. Our results support a distinct magnetic transition at the surface in the Kosterlitz-Thouless universality class.

Public support for policies to improve the nutritional impact of the Supplemental Nutrition Assistance Program (SNAP)

OBJECTIVE

To determine public attitudes towards federal spending on nutrition assistance programmes and support for policies to improve the nutritional impact of the Supplemental Nutrition Assistance Program (SNAP).

DESIGN

Participants answered survey questions by telephone assessing support for SNAP spending and proposed programme policy changes.

SETTING USA SUBJECTS

Survey of 3024 adults selected by random digit dialling conducted in April 2012, including 418 SNAP participants.

RESULTS

A majority (77%; 95% CI 75, 79%) of all respondents supported maintaining or increasing SNAP benefits, with higher support among Democrats (88%; 95% CI 86, 90%) than Republicans (61%; 95% CI 58, 65%). The public supported policies to improve the nutritional impact of SNAP. Eighty-two per cent (95% CI 80, 84%) of respondents supported providing additional benefits to programme participants that can only be used on healthful foods. Sixty-nine per cent (95% CI 67, 71%) of respondents supported removing SNAP benefits for sugary drinks. A majority of SNAP participants (54%; 95% CI 48, 60%) supported removing SNAP benefits for sugary drinks. Of the 46% (95% CI 40, 52%) of SNAP participants who initially opposed removing sugary drinks, 45 % (95% CI 36, 54%) supported removing SNAP benefits for sugary drinks if the policy also included additional benefits to purchase healthful foods.

CONCLUSIONS

The US public broadly supports increasing or maintaining spending on SNAP. The majority of respondents, including SNAP participants, supported policies to improve the nutritional impact of SNAP by restricting the purchase of sugary drinks and incentivizing purchase of healthful foods with SNAP benefits.

School-day and overall physical activity among youth

BACKGROUND

Increasing school-day physical activity through policy and programs is commonly suggested to prevent obesity and improve overall child health. However, strategies that focus on school-day physical activity may not increase total physical activity if youth compensate by reducing physical activity outside of school.

PURPOSE

Objectively measured, nationally representative physical activity data were used to test the hypothesis that higher school-day physical activity is associated with higher overall daily physical activity in youth.

METHODS

Accelerometer data from 2003-2004/2005-2006 National Health and Nutrition Examination Surveys were analyzed in 2012 to estimate physical activity levels during the school day (8AM-3PM) among youth aged 6-19 years (n=2548). Fixed-effects regressions were used to estimate the impact of changes in school-day minutes of moderate-to-vigorous physical activity (MVPA) on changes in total daily MVPA.

RESULTS

Each additional minute of school-day MVPA was associated with an additional 1.14 minutes (95% CI=1.04, 1.24; p<0.001) of total daily MVPA, or 0.14 additional minutes (95% CI=0.04, 0.24; p=0.008) outside the school day, controlling for total daily accelerometer wear time and age, gender, race/ethnicity, and other non-time varying covariates. There were no differences in the effect of school-day MVPA on total MVPA by age group, gender, race/ethnicity, poverty status, or degree of change in MVPA.

CONCLUSIONS

Higher school-day MVPA was associated with higher daily MVPA among U.S. youth with no evidence for same-day "compensation." Increasing school-based physical activity is a promising approach that can improve total daily physical activity levels of youth.

Impact of Connecticut legislation incentivizing elimination of unhealthy competitive foods on National School Lunch Program participation

OBJECTIVES

We analyzed the impact of Connecticut legislation incentivizing voluntary school district-level elimination of unhealthy competitive foods on National School Lunch Program (NSLP) participation.

METHODS

We analyzed data on free, reduced, and paid participation in the NSLP from 904 schools within 154 Connecticut school districts from the 2004-2005 to the 2009-2010 school year, resulting in 5064 observations of annual school-level meal participation. We used multilevel regression modeling techniques to estimate the impact of the state competitive food legislation on the count of NSLP lunches served per student in each school.

RESULTS

Overall, the state statute was associated with an increase in school lunch participation. We observed increases between 7% and 23% for middle- and high-school meal programs, and a slight decrease of 2.5% for the elementary school free meal eligibility category, leading to an estimated revenue increase of roughly $30 000 for an average school district per school year.

CONCLUSIONS

This study provides support for national implementation of proposed rigorous competitive food standards that can improve the health of students while supporting local school district finances.