1. Improving Lifestyles, Tackling
Obesity: Assessing the Health
and Economic Impact of
Prevention Strategies
Michele Cecchini MD, MSc
Health Policy Analyst, OECD
2. Chronic Diseases and Prevention
• Increasing prevalence of chronic diseases
in the OECD area
– Incidence is increasing (ageing, lifestyles)
– Mortality is decreasing (better healthcare)
• Some risk factors are declining (e.g.
smoking)…
• … but others are rising (e.g. unhealthy diet
and physical inactivity)
• Prevention or treatment?
3. Are Prevention Interventions Justified?
It is better to be healthy than ill or dead.
That is the beginning and the end of the only
real argument for preventive medicine.
It is sufficient.
Geoffrey Rose
4. The Goals of Prevention
Prevention may offer opportunities to:
• Increase social welfare
• Enhance health equity
Relative to a situation in which chronic diseases
are treated when they emerge
5. “Maintaining good health is an important goal for
most individuals, but health is by no means the
only outcome that individuals value when they
choose how to lead their own lives. Individuals
wish to engage in activities from which they
expect to derive pleasure, satisfaction, or
fulfilment, some of which may be conducive to
good health, others less or not at all. […] An
assessment of the role of prevention must not
ignore those competing goals” (Sassi and Hurst, 2008)
Are Prevention Interventions Justified?
6. • Market and rationality failure:
– Externalities
– Information failures
– Supply-side market failures
– Failures of rationality
• Existing policies have undesired effects
• Health inequalities
Are Prevention Interventions Justified?
7. Education and Smoking
From D. Kenkel’s presentation at OECD Expert Group meeting, 27 April 2007.
Smoking risk knowledge and degree Smoking prevalence and degree
8. Concerns About Rising Obesity
• Evidence consistently shows rising overweight
and obesity rates in OECD area
• No sign of decline or slowdown
• BMI distributions are shifting following similar
patterns across countries and over time
• Countries with the lowest overweight prevalence
today will have caught up with high prevalence
rates within 10 years
9. Obesity: a Growing Problem
20%
30%
40%
50%
60%
70%
80%
1970 1980 1990 2000 2010 2020
Proportionoverweight(adultpopulation)
Year
USA England
Spain
Austria
France
Australia
Canada
Korea
Italy
10. What Policy Options?
Interventions assessed on the basis of interference
with individual choice:
1. Actions that widen the choice set or decrease the
price (opportunity cost) of selected choice options;
2. Actions that influence choices through means
other than prices, such as persuasion, provision of
information, or other suitable means;
3. Actions that increase the price (opportunity cost)
of selected choice options;
4. Actions that restrict the choice set by banning
selected choice options
11. What Policy-Makers Want to Know
• Does prevention improve health?
• Does it reduce health expenditure?
• Does it improve health inequalities?
• Is it cost-effective?
12. Expectations Must Be Realistic
0%
4%
8%
12%
16%
20%
24%
28%
32%
36%
Cost-saving < 10,000 10,000 to
50,000
50,000 to
100,000
100,000 to
250,000
250,000 to
1,000,000
≥
1,000,000
increases
cost and
worsen
health
Proportionofpublishedcost-effectivenessratios
Cost-effectiveness ratio ($ per QALY)
Preventive measures Treatments for existing conditions
Adapted from Cohen JT, et al. NEJM 2008;358(7):661-3
13. Physical activity
P0 adequate physical act
P1 insuff .physical act
Body mass
index
N normal weight
U pre-obesity
V obesity
Blood pressure
Z0 normal
Z1 hypertension
Cholesterol
A0 normal
A1 hypercholesterolemia
Glycaemia
B0 normal
B1 diabetes
Cancers
Stroke
Ischemic heart
disease
Distal risk factors
Intermediate risk
factor
Proximal risk factors Diseases
Fat
F0 low fat intake
F1 medium fat intake
F2 high fat intake
Fibre
Y0 adequate fibre intake
Y1 low fibre intake
Socio-economic status
I0 upper
I1 lower
14. Interventions
Health education and
health promotion
Regulation
and fiscal measures
Primary-care based
interventions
Mass media campaigns
Fiscal measures
(fruit and vegetables and foods
high in fat)
Physician counselling
of individuals at risk
School-based
interventions
Government regulation or
industry self-regulation of
food advertising to
children
Intensive physician and
dietician counselling of
individuals at risk
Worksite interventions
Compulsory food
labelling
17. Health Outcomes of Prevention
0 100,000 200,000 300,000 400,000 500,000
physician-dietician counselling
fiscal measures
physician counselling
food labelling
worksite interventions
food advertising regulation
school-based interventions
food adverting self-regulation
mass media campaigns
Disability-adjusted life years Life years
1 LY/DALY every 115/121 people
1 LY/DALY every 12/10 people
18. Health Outcomes over Time
England
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
0 10 20 30 40 50 60 70 80 90 100
DALYs(permillionpopulation)
Time (years)
school-based
interventions
worksite
interventions
mass media
campaigns
fiscal measures
physician
counselling
physician-
dietician
counselling
food
advertising
regulation
food adverting
self-regulation
food labelling
19. Intervention Effectiveness
(coverage)
Working for large employer [63%]
Employed [64%]
Population aged 18-65 [64%]
Participating
employers [50%]
Participating
employees
[45%]
Coverage = 5.8% of the population
Worksite interventions
20. Intervention Effectiveness
(Time to Steady State)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 98 99 100
1
2
3
90
91
age
period
0 10 20 30 40 50 60 70 80 90 100
school-based int
food advert reg
food advert self-reg
worksite interv
physician couns
phys/diet couns
mass media camp
food labelling
fiscal measures
years to
steady
state
23. Health Outcomes and Expenditure
Physician-Dietician Counselling
-15000-10000-10000
Health outcomes Impact on health expenditure
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
life years (thousands) DALYs (thousands)
-15,000
-10,000
-5,000
0
5,000
10,000
costs (million $PPP)
26. Impact on Inequalities
Different social groups have:
• Different risk profiles:
– Larger benefits in those most at risk (~)
• Different responses to interventions:
– Larger benefits with a greater response
33. Multiple interventions
Health outcomes Impact on health expenditure
(selected diseases)
Multiple int. 1 school-based intervention + mass media camp + physician-dietician counselling
Multiple int. 2
food labelling + food advert self-regulation + school-based interventions + mass media
campaigns + physician-dietician counselling
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
Life years (thousands)
Disability-adjusted life years (thousands)
-70,000
-60,000
-50,000
-40,000
-30,000
-20,000
-10,000
0
Impact on health expenditure (million $PPP)
34. Multiple Interventions
050100150200250300350400
Cost-effectiveness ratio (thousand $PPP per DALY)
50,000$PPP/DALY
morethan1,000,000$PPP/DALY
0 25 50 75 100
Cost-effectiveness ratio (thousand $PPP per DALY)
50,000$PPP/DALY
Fiscal measures
Mass media camp
Phys-diet couns.
Food labelling
Multiple int. 2
Multiple int. 1
Physician couns.
Worksite interv.
Food adv self-reg.
Food advert.
School-based int.
Cost-effectiveness of interventions after 10 years Cost-effectiveness of interventions after 100 years
35. Policy Implications
• Prevention is an effective and cost-effective way to
improve population health
• Prevention can decrease health expenditure and
improve inequalities, but not to a major degree
• Comprehensive strategies combining population
and individual approaches provide best results
• Involvement of relevant stakeholders is key to the
success of prevention
36. OECD work on prevention
• Obesity and the economics
of prevention: fit not fat
• OECD health working papers
HWP 32, 45, 46, 48
• Paper in Lancet series on
chronic diseases
(forthcoming)
www.oecd.org/health/prevention www.oecd.org/health/fitnotfat michele.cecchini@oecd.org
