Modeling the Cost Effectiveness of Child Care Policy Changes in the U.S.
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
References (82)
Morbidity and mortality associated with elevated body weight in children and adolescents
Am J Clin Nutr
(1996)- et al.
Children׳s food preferences: a longitudinal analysis
J Am Diet Assoc
(2002) - et al.
Tracking of obesity-related behaviours from childhood to adulthood: a systematic review
Maturitas
(2011) - et al.
Factors associated with physical activity in preschool children
J Pediatr
(2002) - et al.
What role can child-care settings play in obesity prevention? A review of the evidence and call for research efforts
J Am Diet Assoc
(2011) The physical activity levels of preschool-aged children: a systematic review
Early Child Res Q
(2008)- et al.
Dietary intakes in North Carolina child-care centers: are children meeting current recommendations?
J Am Diet Assoc
(2008) - et al.
Assessing foods offered to children at child-care centers using the Healthy Eating Index-2005
J Acad Nutr Diet
(2013) - et al.
Preschoolers׳ total daily screen time at home and by type of child care
J Pediatr
(2011) - et al.
Physical activity and beverages in home- and center-based child care programs
J Nutr Educ Behav
(2012)
Cost effectiveness of childhood obesity interventions: evidence and methods for CHOICES
Am J Prev Med
Dynamics of childhood growth and obesity: development and validation of a quantitative mathematical model
Lancet Diabetes Endocrinol
Nutrition and physical activity in child care: results from an environmental intervention
Am J Prev Med
Cost effectiveness of a sugar-sweetened beverage excise tax in the U.S.
Am J Prev Med
Increasing physical activity in preschool: a pilot study to evaluate animal trackers
J Nutr Educ Behav
Cost effectiveness of an elementary school active physical education policy
Am J Prev Med
BMI and healthcare cost impact of eliminating tax subsidy for advertising unhealthy food to youth.
Am J Prev Med
Effects of a controlled trial of a school-based exercise program on the obesity indexes of preschool children
Am J Clin Nutr
Prevalence and trends in obesity and severe obesity among children in the United States, 1999-2012
JAMA Pediatr
Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001
JAMA
Tracking of physical activity in young children
Med Sci Sports Exerc
Prevalence, correlates, and trajectory of television viewing among infants and toddlers
Pediatrics
Position of the American Dietetic Association: benchmarks for nutrition programs in child care settings
J Am Diet Assoc
Family and child-care provider influences on preschool children׳s fruit, juice, and vegetable consumption
Nutr Rev
The role of child care settings in obesity prevention
Future Child
Childhood obesity: shifting the focus to early prevention
Arch Pediatr Adolesc Med
Preventing Obesity In The Child Care Setting: Evaluating State Regulations
Child care as an untapped setting for obesity prevention: state child care licensing regulations related to nutrition, physical activity, and media use for preschool-aged children in the United States
Prev Chronic Dis
A review of state regulations to promote physical activity and safety on playgrounds in child care centers and family child care homes
J Phys Act Health
Best-practice guidelines for physical activity at child care
Pediatrics
American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics
Pediatrics
Early Childhood Obesity Prevention Policies: Goals, Recommendations, and Potential Actions
A statewide strategy to battle child obesity in Delaware
Health Aff (Millwood)
Cost-effectiveness of diet and exercise interventions to reduce overweight and obesity
Int J Obes (Lond)
Priority setting in health: origins, description and application of the Australian Assessing Cost-Effectiveness initiative
Expert Rev Pharmacoecon Outcomes Res
Public health interventions for addressing childhood overweight: analysis of the business case
Am J Public Health
Cited by (26)
Change in the implementation of healthy nutrition and physical activity best practices in Minnesota early care settings: A longitudinal cohort study (2010–2016)
2018, Preventive Medicine ReportsCitation Excerpt :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).
Pilot survey of a novel incentive to promote healthy behavior among school children and their parents
2017, Preventive Medicine ReportsCitation Excerpt :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.
Using cost-effectiveness analysis to prioritize policy and programmatic approaches to physical activity promotion and obesity prevention in childhood
2017, Preventive MedicineCitation Excerpt :We used the Childhood Obesity Intervention Cost Effectiveness Study (CHOICES) systematic review process to identify the six interventions with substantial evidence for effectiveness in various settings and age groups. The CHOICES evaluation process is modeled after the Australian Assessing Cost-Effectiveness approach (Carter et al., 2009; Carter et al., 2008) and includes a structured process of engaging a group of national stakeholders in selection of intervention strategies, consultation regarding evidence for effectiveness, potential to reduce obesity, and discussion of implementation and equity issues (Gortmaker et al., 2015a, 2015b; Long et al., 2015; Sonneville et al., 2015; Wright et al., 2015; Barrett et al., 2015). We used an individual level microsimulation model of the population in the United States to project outcomes of the national implementation of each intervention using U.S. population, mortality, and health care cost data from 2015 to 2025; the model has been described in detail elsewhere (Gortmaker et al., 2015a).
Process evaluation of a preschool physical activity intervention using web-based delivery
2017, Evaluation and Program PlanningCost Effectiveness of Childhood Obesity Interventions: Evidence and Methods for CHOICES
2015, American Journal of Preventive MedicineCitation Excerpt :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.
A Narrative Review of Public Health Interventions for Childhood Obesity
2024, Current Obesity Reports