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

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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/m2, 0.0434 kg/m2) 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.

Introduction

More than 20% of preschool-aged children in the U.S. are overweight or obese.1 Early obesity is a risk factor for hypertension, Type 2 diabetes, cancers, and psychosocial issues throughout the life course.2, 3 Risk factors for obesity, including dietary habits, physical activity, and screen time behaviors, track from early into later childhood,4, 5, 6 and then persist from childhood into adulthood.7 The risk of early obesogenic behaviors persisting over the life course and the difficulty of changing long-term habits in adulthood highlight the importance of early intervention for obesity prevention.

Approximately 69% of American preschool-aged children used an out-of-home child care provider in 2005.8 Full-day programs are responsible for up to two thirds of children’s food intake per day in care.9, 10 Child care providers also often provide daily opportunities for children to participate in physical activity.11, 12 Given the importance of addressing obesity early,13 the length of time children spend in the child care environment, and the influence child care facilities have on healthy behaviors, the child care setting is an ideal intervention target.11

Child care policies can be influenced by many actors—state licensing agencies, federal nutrition programs such as Head Start or the Child and Adult Care Food Program (CACFP), and other accreditation organizations. Many of these programs encourage serving reduced-fat milk and limiting servings of sugar-sweetened beverages (SSBs) and 100% juice. However, not all child care providers are under the jurisdiction of national nutrition programs or accrediting bodies, and instead may be subject to state or local policies that vary widely.14 Physical activity and screen time policies are sometimes regulated by state licensing agencies, but regulations often do not strictly limit sedentary behaviors.14, 15

Some studies have examined the efficacy of single- and multi-component obesity prevention initiatives in the child care setting.16 However, no studies have examined the cost of conducting an obesity prevention policy initiative in the child care setting. This study estimates the health and economic impact of obesity prevention policy changes in child care environments in the U.S. to bridge this gap in the literature.

Section snippets

Intervention

A hypothetical state-level regulatory policy intervention was developed for this analysis. The intervention was based on current recommendations regarding healthy behavior practices in child care programs14, 17, 18, 19, 20, 21 and current state and local child care initiatives.22, 23, 24 The intervention consisted of three components. The beverage component stipulated that water be made freely available throughout the program day, that SSBs be replaced with water, 100% juice be limited to 6

Results

An estimated 6.5 million of the 14.4 million preschool-aged children in the U.S. used child care facilities in 2015. The reach of the policy was mitigated by facility non-compliance (26%) and baseline state compliance with proposed policies. After consideration of these mitigating factors, the primary diet, physical activity, and screen time components were estimated to have reached 3.69, 3.32, and 1.63 million children, respectively.

The 1-year expected BMI change from the intervention versus

Discussion

This is the first study to examine the potential economic impact of a multi-component child care–based obesity policy intervention. Implementing comprehensive obesity prevention policies in child care facilities appears to be a viable and cost-effective obesity prevention strategy. The modeled child care facility policy changes resulted in an estimated 0.0186 kg/m2 per child decrease in BMI among the eligible population of 6.5 million American preschool-aged children at a cost of $57.80 per BMI

Acknowledgments

This work was supported in part by grants from the Robert Wood Johnson Foundation (#66284), Donald and Sue Pritzker Nutrition and Fitness Initiative, JPB Foundation, and is a product of a Prevention Research Center supported by Cooperative Agreement U48/DP001946 from CDC, including the Nutrition and Obesity Policy Research and Evaluation Network. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of CDC. The authors

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      However, reviewing interventions within ECE settings that aimed to limit unhealthy weight gain and promote healthy weight management reveals mixed results (Hesketh and Campbell, 2010; Campbell and Hesketh, 2007; Sisson et al., 2016). Recent literature suggests improved regulatory policy within ECE settings may offer a promising alternative to individual interventions by yielding more favorable child diet, activity and weight outcomes as well as broader societal level economic impacts (Ritchie et al., 2015; Wright et al., 2015). To achieve improved child health outcomes, national association experts recommend better alignment between best practices grounded in scientific evidence and state regulatory policy (Buscemi et al., 2015; Benjamin Neelon and Briley, 2011).

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      Obesity also imposes social costs through disability and lost productivity (Committee on Accelerating Progress in Obesity Prevention, Food and Nutrition Board (FNB) & Institute of Medicine (IOM), 2012; MacEwan et al., 2014). Prior studies have evaluated various interventions to improve behaviors for obesity prevention such as school-based child obesity interventions (Wang et al., 2013; Waters et al., 2011; Oude Luttikhuis et al., 2009; Martin et al., 2014; Wyatt et al., 2013), family support (Epstein et al., 1990; Epstein et al., 1994; Kitzmann & Beech, 2006; Wrotniak et al., 2004; Drury et al., 2013; Epstein et al., 2014; Wilfley et al., 2007), peer support (McLean et al., 2003; Cohen et al., 1987; Jeffery et al., 1983; Osilla et al., 2012; Paul-Ebhohimhen & Avenell, 2009), competition/performance-based financial incentives (Martin et al., 2014; Wyatt et al., 2013; Drury et al., 2013; Jeffery et al., 1983; Volpp et al., 2008; Paul-Ebhohimhen & Avenell, 2008; You et al., 2012; Hersey et al., 2008; Hubbert et al., 2003; Sykes-Muskett et al., 2015; Mantzari et al., 2015; Purnell et al., 2014; Mayor, 2013; Mitchell et al., 2013; Burns et al., 2012; Kullgren et al., 2013; Crane et al., 2012; Finkelstein et al., 2013; Hunter et al., 2016; Ngo et al., 2014; Patel et al., 2016; Simpson et al., 2015; Finkelstein et al., 2016; Finkelstein et al., 2015; Hunter et al., 2015), donation to charity (Finkelstein et al., 2016; Finkelstein et al., 2015; Hunter et al., 2015), and a regulatory obesity policy in child care facilities (Wright et al., 2015). For instance, one study asked adults about their preferences for a hypothetical set of obesity prevention intervention incentives (You et al., 2012) which varied in the reward form, amount, and timing.

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      state policy requiring all public elementary schools in which physical education (PE) is currently provided to devote ≥50% of PE class time to moderate and vigorous physical activity (Active PE)30; and state policy to make early child educational settings healthier by increasing physical activity, improving nutrition, and reducing screen time (ECE).31 Interventions were specified including the setting (e.g., schools for Active PE, states for SSB), target population, and intervention activities.

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