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

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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.

Introduction

The childhood obesity epidemic has been growing for decades in countries throughout the world, and policymakers, scientists, and the public have all been engaged in a search for interventions that can reverse these trends. Many approaches have been tried, including programmatic and policy interventions that target either children only or the general population. This variety reflects the many forces that have been identified as driving the epidemic and influencing trends in obesity disparities.1 The evidence base for effective interventions in the U.S. is evolving, but there have been limited quantitative and economic analyses of population-based interventions, as opposed to individual-based approaches, and few comparisons across multiple approaches.2, 3 With fiscal crises affecting both federal and state governments, U.S. policymakers are now asking not only whether an intervention works but also whether it offers good value for money spent and potential cost savings.

Cost-effectiveness analyses can provide just such information,4, 5, 6, 7, 8, 9, 10, 11, 12, 13 but there are substantial challenges in examining the cost effectiveness of childhood obesity interventions. One major challenge is that childhood interventions incur costs “up front” as they are implemented, but their most substantial health benefits (e.g., reductions in morbidity) are minimal until decades later at age 35 years and older, when obesity-related diseases become more prevalent.14 Childhood interventions thus must have a sustained impact over a very long time period to affect these outcomes, and assuming that effects of childhood interventions persist over decades may be unrealistic.6, 15 Although there are examples of childhood obesity interventions showing effectiveness for 5 and 10 years,16, 17, 18, 19 to the authors’ knowledge, no studies show effectiveness for 20–40 years. Therefore, the current analyses focused primarily on short-term and 10-year cost effectiveness, including cost per unit of BMI reduction and obesity-related healthcare costs averted.5, 20

Though evidence for the long-term maintenance of childhood interventions is unclear, preventive intervention strategies in childhood still have great potential to avert adulthood obesity. Few children are born with obesity, and the changes needed to reduce childhood excess weight are much smaller than those needed to change adult excess weight.21, 22, 23 There is substantial tracking of adolescent obesity into adulthood,24, 25 and it is clear that, once obesity is established in adulthood, treatment has limited effects on long-term outcomes.26 Therefore, prevention of obesity in childhood is critical in the prevention of adult obesity, and the identification of cost-effective interventions that can be applied throughout childhood is a clear priority.27

In this paper, initial results are reported from the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES), a collaborative modeling effort to provide estimates of the effectiveness, costs, reach, and cost effectiveness of interventions to reduce childhood obesity in the U.S. Detailed description of data inputs, assumptions, and findings for each intervention are reported in separate papers.28, 29, 30, 31 This overview paper discusses the common approach and methods used in analyses, and compares results across the four studies.

The CHOICES work is built on a framework developed for the Australian Assessing Cost-Effectiveness (ACE)32, 33 in Obesity6 and ACE-Prevention modeling studies.7 The CHOICES study is one of the first efforts to estimate the cost effectiveness of a range of nationally implemented childhood obesity interventions in the U.S.

Section snippets

Methods

The methods and results presented here are the outgrowth of collaborations among researchers at the Harvard School of Public Health and the Columbia University Mailman School of Public Health in the U.S., and Deakin and Queensland Universities in Australia. CHOICES methods were built on the ACE approach of using standard evaluation methods to develop a priority setting process that balances technical rigor with due process.32, 33

The ACE approach was adapted by taking into account the U.S.

Results

Results of the four cost-effectiveness analyses are summarized in Table 1, Table 2. The short-term outcomes described in Table 1 included the population reached by the interventions— which varied greatly, from the 3.7 million children estimated to be impacted by the ECE intervention to the 313 million children and adults who would be affected by an SSB excise tax. The estimated annual cost of the interventions also varied substantially, ranging from a low of $1.1 (95% UI=$0.69, $1.42) million

Discussion

The relative cost effectiveness of the four intervention studies reviewed here provides an important series of contrasts. The estimated costs, cost effectiveness, and reach of these interventions as they are brought to scale nationally vary dramatically. The cost per BMI unit change for three of the interventions varies from $1.16 to $57.80, and the most expensive was $401. Are these costs low or high? There are no established benchmarks for cost per unit changes in BMI, but one relevant

Acknowledgments

This work was supported in part by grants from the Robert Wood Johnson Foundation (#66284) and CDC (U48/DP00064-00S1), including the Nutrition and Obesity Policy, Research and Evaluation Network, a Centre for Research Excellence in Obesity Policy and Food Systems supported by the Australian National Health and Medical Research Centre (grant number 1041020), the Donald and Sue Pritzker Nutrition and Fitness Initiative, and the JPB Foundation. This work is solely the responsibility of the authors

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