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Steven Gortmaker, Sugar Sweetened Beverage Taxes: Impact on Health, Health Care Costs, and Health Disparities

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Steven Gortmaker, Sugar Sweetened Beverage Taxes: Impact on Health, Health Care Costs, and Health Disparities

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February 14, 2020

On February 14, 2020, Harvard Medical School Center for Bioethics and the Program on Regulation, Therapeutics, and Law (PORTAL) at Brigham and Women's Hospital, in collaboration with the Petrie-Flom Center hosted the monthly health policy consortium on sugar-sweetened beverage excise taxes.

In recent years, some cities have tried to impose soda taxes and other new policies to reduce the obesity epidemic in the US—particularly among children—and its critical impact on society and the health care system. How effective are these policies? What is blocking their uptake? What alternatives should we consider?

For more information visit our website at: https://petrieflom.law.harvard.edu/events/details/soda-taxes-and-other-policy-responses-to-the-american-obesity-epidemic

February 14, 2020

On February 14, 2020, Harvard Medical School Center for Bioethics and the Program on Regulation, Therapeutics, and Law (PORTAL) at Brigham and Women's Hospital, in collaboration with the Petrie-Flom Center hosted the monthly health policy consortium on sugar-sweetened beverage excise taxes.

In recent years, some cities have tried to impose soda taxes and other new policies to reduce the obesity epidemic in the US—particularly among children—and its critical impact on society and the health care system. How effective are these policies? What is blocking their uptake? What alternatives should we consider?

For more information visit our website at: https://petrieflom.law.harvard.edu/events/details/soda-taxes-and-other-policy-responses-to-the-american-obesity-epidemic

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Steven Gortmaker, Sugar Sweetened Beverage Taxes: Impact on Health, Health Care Costs, and Health Disparities

  1. 1. Sugar Sweetened Beverage Excise Taxes: Impact on Health, Health Care Costs, and Health Disparities Steven Gortmaker PhD Harvard Law School February 14, 2020
  2. 2. CHOICES PROJECT This work was supported in part by grants from The JPB Foundation, the National Institutes of Health (R01HL146625), the Robert Wood Johnson Foundation(#66284), the Donald and Sue Pritzker Nutrition and Fitness Initiative and the Centers for Disease Control and Prevention (U48DP001946), including the Nutrition and Obesity Policy, Research and Evaluation Network. This work is solely the responsibility of the authors and does not represent official views of the CDC or other funders
  3. 3. The Challenge o Obesity rates are at historically high levels ages 2- 19 o Racial/ethnic & economic disparities persist Ward et al., N Engl J Med, 2017 Ward ZJ, Bleich SN, Cradock AL, Barrett JL, Giles CM, Flax C, Long MW, Gortmaker SL, N Engl J Med, 2019 Flegal et al., JAMA, 2016 Ogden et al., JAMA, 2016 Research continues to show that more and more people have developed obesity in the U.S. o About half of the adult U.S. population will have obesity and about a quarter will have severe obesity by 2030
  4. 4. Ward ZJ, Long MW, Resch SC, Giles CM, Cradock AL, Gortmaker SL. N Engl J Med, 2017. Doing nothing to address childhood obesity is not an option
  5. 5. Costs of adults with excess weight Wang YC, Pamplin J, Long MW, Ward ZJ, Gortmaker SL, Andreyeva T. (2015) Severe Obesity in Adults Cost State Medicaid Programs Nearly $8 Billion in 2013. Health Aff 34:1923-2931 Obesity health care costs are $116 billion per year Severe obesity (BMI >35) accounts for $69 billion of this
  6. 6. What can we do about this? o There is strong evidence linking intake sugar sweetened beverages to excess weight gain and future chronic disease o Note that research supporting this work has occurred just in the past two decades (Our Lancet study in 2001 was the first longitudinal study showing the link to obesity in youth) o Added sugars are mainly found in SSBs in the US. These are generally nutritionally poor beverages – sugar and water and some flavoring. Malik VS, Pan A, Willett WC, Hu FB. Am J Clin Nutr. 2013 Oct;98(4):1084-102. Ludwig DS, Peterson KE, Gortmaker SL. Lancet. 2001 Feb 17;357(9255):505-8.
  7. 7. Why Reduce Sugar Drink Intake? U.S. Dietary Guidelines 2015-2020 Figure 2-9. Average Intakes of Added Sugars as a Percent of Calories per Day by Age-Sex Group, in Comparison to the Dietary Guidelines Maximum Limit of Less Than 10 Percent of Calories
  8. 8. Why Reduce Sugar Drink Intake? U.S. Dietary Guidelines 2015-2020 Figure 2-10. Food Category Sources of Added Sugars in the U.S. Population Ages 2 Years and Older
  9. 9. CHOICES- Why are we doing this? Policies and programs improving nutrition and physical activity environments Best results for dollars invested We want to improve population health via public policies and programs Gortmaker SL, Claire Wang Y, Long MW, Giles CM, Ward ZJ, Barrett JL, Kenney EL, Sonneville KR, Afzal AS, Resch SC, Cradock AL. Three Interventions That Reduce Childhood Obesity Are Projected to Save More Than They Cost to Implement. Health Affairs, 34, no. 11 (2015):1304-1311.
  10. 10. Cost-effectiveness analysis Cost-Effectiveness Analysis compares the costs and outcomes of: One policy or program intervention with no intervention Two or more policy or program interventions OR vs. vs.
  11. 11. More Informed Decision-Making o Cost-effectiveness framework provides an opportunity across strategies and health outcomes for better decision making • Evidence for impact on health • Population reach • Implementation resources, activities & costs • Potential impact on disparities
  12. 12. Costs & outcomes Difference in Effectiveness DifferenceinCost + +– – Lower costs Better outcome Higher costs Better outcome Higher costs Worse outcome Lower costs Worse outcome
  13. 13. Costs & outcomes Difference in Effectiveness DifferenceinCost + +– – Lower costs Better outcome Higher costs Better outcome Higher costs Worse outcome Lower costs Worse outcome
  14. 14. How the Microsimulation Model Works
  15. 15. Project impact on the population The CHOICES microsimulation model projects the future course of the childhood obesity epidemic by evaluating how an identified strategy will impact obesity, healthcare costs & mortality outcomes over 10 years
  16. 16. CHOICES model intervention inputs Reach Who will benefit? Effect What is effect of the policy/program on health? Cost Implementation costs of program/policy and healthcare cost savings Focus on implementation of interventions to improve nutrition & physical activity environments Dietz WH, Gortmaker SL. New Strategies to Prioritize Nutrition, Physical Activity, and Obesity Interventions. Am J Prev Med. 2016 Apr 26. pii: S0749-3797(16)30069-1.
  17. 17. How does an SSB Excise Tax work? o Most current SSB taxes are volume taxes – say $0.01 per oz (Berkeley CA), or $0.02 per oz (Boulder CO). ($0.0175 oz on Seattle) o You can also tax the amount of sugar (e.g. UK). o Note this is not a sales tax o The tax raises the price, so people buy less and then consume less, potentially leading to less excess weight gain and reduced risk of future chronic disease o This approach worked well with tobacco
  18. 18. How the CHOICES Model Works OUTCOMES Simulate to: 2025 Healthcare Costs Mortality Obesity HEALTH STATUS BMI INDIVIDUAL Body Growth Personal Characteristics (e.g. dietary intake) Smoking POPULATION Population Growth BMI Trends Start: 2015 VIRTUAL POPULATION From 2010 U.S. Census Data BASELINE SCENARIO Obesity QALYs
  19. 19. OUTCOMES Simulate to: 2025 Healthcare Costs Mortality Obesity HEALTH STATUS Obesity How the CHOICES Model Works INTERVENTION SCENARIO INTERVENTION DietaryIntake/PhysicalActivity INDIVIDUAL FACTORS Body Growth Personal Characteristics (e.g. dietary intake) Smoking POPULATION FACTORS Population Growth BMI Trends Start: 2015 VIRTUAL POPULATION From 2010 U.S. Census Data INTERVENTION SCENARIO
  20. 20. What has CHOICES been finding? Some strategies are cost-saving Many strategies reaching only children require investment Include adults for immediate large health care cost savings Strategies across sectors improve population health Some strategies projected to reduce disparities
  21. 21. OVERVIEW OF SELECTED CHOICES NATIONAL MODEL RESULTS
  22. 22. 22 CHOICES Metrics: 3 examples Metric Definition Cases of Childhood Obesity Prevented in 2025 How many cases of childhood obesity will be prevented in the intervention model compared to no intervention in 2025? Net costs The cost of implementing the intervention minus the health care cost savings; a negative number means intervention is cost saving Health Care Cost Saved per $1 Invested For every $1 invested to implement the intervention, how much money is saved in health care costs with the reduction in obesity in the population?
  23. 23. NET COST SAVINGS AFTER 10 YEARS CASES OF CHILDHOOD OBESITY PREVENTED IN 2025 NET COST AFTER 10 YEARS Example: Interventions to reduce childhood obesity 1The SSB Tax intervention would also produce an estimated $12.5 (2015) billion/year in tax revenue. This is not included in the cost-effectiveness analysis 2 95% uncertainty interval 576,000SSB Tax1 $-14.2 billion ($-2.65, $-47.1)2 (132,000, 1,890,000)2 Smart Snacks $-792 million 344,649 ($-251, $-1,340)2 (163,000, 522,000)2 Bariatric Surgery $303 million No cases ($209, $401)2
  24. 24. No effect on cases HEALTH CARE COST SAVINGS Per $1 INVESTED1 Bariatric Surgery 1Gortmaker SL, Claire Wang Y, Long MW, Giles CM, Ward ZJ, Barrett JL, Kenney EL, Sonneville KR, Afzal AS, Resch SC, Cradock AL. Three Interventions That Reduce Childhood Obesity Are Projected to Save More Than They Cost to Implement. Health Affairs, 34, no. 11 (2015):1304-1311. 2 95% uncertainty intervals Example: Interventions to reduce childhood obesity $30.80 ($6.10, $113)2 SSB Tax $4.60 ($2.10, $7)2 Smart Snacks
  25. 25. Impact of SSB Excise Tax on Percentage Reduction (95% UI) in Childhood Obesity Prevalence, by Race/Ethnicity 0.77% 1.04% 1.02% 0.00% 0.50% 1.00% White Black Hispanic 1.32 times greater, compared to White Long MW, Ward ZJ, Barrett JL, Cradock AL, Resch SC, Wang, YC, Giles CM, Gortmaker, SL. Taxing Sugar-sweetened Beverages Estimated to Reduce Racial/Ethnic Disparities in U.S. Obesity Prevalence. American Public Health Association, Denver CO, 2016. 1.35 times greater, compared to White
  26. 26. 0.91% 0.87% 0.86% 0.80% 0.00% 0.20% 0.40% 0.60% 0.80% 1.00% ≤130% poverty level 131-185% poverty level 186-350% poverty level >350% poverty level 1.14 times greater, compared to highest income 1.09 times greater, compared to highest income Impact of SSB Excise Tax on Percentage Reduction (95% UI) in Childhood Obesity Prevalence, by household income 1.07 times greater, compared to highest income Long MW, Ward ZJ, Barrett JL, Cradock AL, Resch SC, Wang, YC, Giles CM, Gortmaker, SL. Taxing Sugar-sweetened Beverages Estimated to Reduce Racial/Ethnic Disparities in U.S. Obesity Prevalence. American Public Health Association, Denver CO, 2016.
  27. 27. Summary: Cost-Effectiveness of SSB Excise Tax o A Sugar Sweetened Beverage excise tax ($0.01 per ounce) is projected to prevent future obesity and save more in health care costs than it cost to implement o This strategy will also likely improve population health equity while improving population health overall o In addition, the tax would raise an additional $12.5 billion per year in revenue that could be used for other preventive programs
  28. 28. CHOICES Learning Collaborative Partnership (LCP)
  29. 29. Connect with CHOICES Visit: www.choicesproject.org for more information on publications, news, and collaborations Follow us: @CHOICESProject

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