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Why early prevention of childhood obesity is more than a medical concern- A health economic approach

Diana Sonntag

Mannheim Institute for Public Health (MIPH), Medical Faculty Mannheim of Heidelberg University

Munich, 14 October 2016

Diana Sonntag I MIPH I Slide 2 von 24 14 October 2016

Is childhood obesity a concern?


Future health and economic outcomes

Prevalence of childhood

obesity

Prevalence of adult obesity

Youth outcomes:

-  Morbidity

-  Social and mental health

-  Educational attainment

Adult outcomes:

-  Morbidity and mortality

-  Social and mental health

-  Economic (job)


1.  The economic burden of childhood overweight and obesity

2.  Cost savings of interventions in early childhood

3.  Cost-effectiveness of early prevention and best-practise guidance

4.  Conclusions

Overview


Direct and indirect costs due to …

1)  Increased direct costs = medical costs •  out- and in-patient costs etc.

2)  Increased indirect costs •  parental absence at work due to sick children •  psychosocial problems •  school absence related with -  lower skill attainment, -  lower overall educational performance (quantity

and quality of schooling) substantial later (work-related) productivity losses


Existing Cost-of-illness (COI-) Studies

1. Overweight/obesity in adulthood Prevalence-based n=a lot, some from Germany: Wolfenstetter (2012)

von Lengerke & Krauth (2011) Konnopka et al. (2011)

Incidence-based n=some, none from Germany: Yang & Hall (2008) Tucker et al. (2006)

2. Taking childhood obesity into account Incidence-based only one from USA/Germany: Fernandes (2010) Sonntag et al. (2015a, 2016)


CHILDREN (Age: 3-17)

ADULTS (Age: 18-75)

Model I (epidemiology)

Model IIa including normal weight children

Model IIb including overweight and obese children

Modelling lifetime costs of childhood overweight and obesity



ADULTS (Age: 18-75)







Normalweight

Overweight

Obese

Normalweight (after overweight)

Overweight (after obese)

DEATH

LEGEND: tp_no: transition probability in normal weight to overweight tp_on: transition probability overweight to normalweight tp_oa: transition probability overweight to obese tp_Death_: mortaility rate rr_: relative mortality risk due to overweight and obesity

tp_Death * (rr)

tp_Death *(rr)

tp_oa

tp_no tp_on

Source: Sonntag et al. 2015a, 2016


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

3 8 13

18

23

28

33

38

43

48

53

58

63

68

73

78

83

88

93

98

Prop

ortio

n of

the

coho

rt

Age

Female

Dead

Proportion of obese individuals who were obese as child

Proportion of obese individuals who become obese during adulthood

Proportion of overweight individuals who were overweight as child

Proportion of overweight individuals who become overweight during adulthood

Normalweight

BMI trajectories taking the history of childhood obesity into account

Source: Sonntag et al. 2015a


Direct excess lifetime costs of childhood overweight and obesity

Costs (€ 2010, without discounting) Male Female

Overweight/obese as child 21,804 27,673

Normal weight as child 7,281 8,194

Excess lifetime costs 14,524 19,479

Cost increased by a factor of ... 3 3 Proportion of cost occur after the age of 60 0.67 0.60 Source: Sonntag et al. 2015a


Costs (€ 2010, discounted by 3%) Male Female




Cost increased by a factor of ... 4 5 Proportion of cost occur after the age of 60 0.44 0.32

Discount rate 3% p.a.








Cost increased by a factor of ... 4 5 Proportion of cost occur after the age of 60 0.44 0.32






Normalgewichtig als Kind 1,955 695


Cost increased by a factor of ... 3 4 Proportion of cost occur before the age of 60 0.81 0.79 Source: Sonntag et al. 2016

Indirect excess lifetime costs of childhood overweight and obesity


0.00

500.00

1,000.00

1,500.00

2,000.00

2,500.00

3,000.00

child

hood

adul

thoo

d

child

hood

adul

thoo

d

child

hood

adul

thoo

d

child

hood

adul

thoo

d

child

hood

adul

thoo

d

child

hood

adul

thoo

d

child

hood

adul

thoo

d

11 - 20 21 - 30 31 - 40 41 - 50 51 - 60 61 - 70 71 - 80

Indi

rect

cos

ts in

€

Decade

Indirect costs due to childhood overweight Indirect costs due to childhood obesity

Indirect costs due to adulthood overweight Indirect costs due to adulthood obesity

Indirect excess lifetime costs of childhood overweight and obesity


Economic burden of childhood overweight and obesity

Ø  Excess lifetime costs of childhood overweight and obesity:

Ø Male: €8,471 Ø Female: €9,473

Ø Total cost for the current prevalent population in Germany: €1.8 billion.

Source: Sonntag et al. 2015a, 2016





4.  Conclusions

Overview


1.  Preventive Programmes:

Ø  Effects of most preventive programmes are small; short run treatment effects (Yavuz 2015, Fröschl et al. 2009, Galani and Schneider 2006)

Ø  Prevalence reduction by 1% è €4.1 million cost savings for the current prevalent

population in Germany

Source: Sonntag et al. 2016

Cost savings of interventions in early childhood


2. EvAKuj-Study: Prevalence reduction of 14% is potentially achievable

è indirect lifetime cost will be reduced by 4% (male) and 2% (female)

è €27 million cost savings for the current prevalent population in Germany (only indirect cost)




3. Extreme Scenario: prevalence reduction of overweight and obesity to the

level of the 1990s

è €68 million cost savings for the current prevalent population in Germany (only indirect cost)







4.  Conclusions

Overview


Ø Growing body of literature about effectiveness of early childhood intervention:

Ø Blake-Lomb et al. (2016): Interventions for Childhood Obesity in the First 1,000 Days: A Systematic Review.

Ø Seburg et al. (2015): A review of primary care-based childhood obesity prevention and treatment intervention.

Ø Yavuz et al. (2015): Interventions aimed at reducing obesity in early childhood: a meta-analysis of programs that involve parents.

Ø Wang et al. (2015): What childhood obesity prevention programmes work? A systematic review and meta-analysis.

(Cost-)Effectiveness of early prevention


But what about cost-effectiveness

of early prevention???

Cost-effectiveness of early prevention


Ø Only few health economic evaluations of interventions during childhood.

Ø Most studies assess the cost-effectiveness of school programmes (6-13 years) (Yavuz et al 2015).

Ø The majority of school programmes is cost-effective è good value for money if cost of intervention are lower than 400$ and prevalence of obesity (overweight) has been reduced (increased) by 1% (Trasande 2010).



Source: Heckman 2006



Ø  However: Only six international economic evaluations of early

prevention programmes targeting preschool children and/or their parents were conducted!

Ø  3 main characteristics (Doering et al. 2016): Ø Most programmes were cost-effective or even-cost saving

despite insignificant effect sizes, Ø Incremental-Cost-Effectiveness-Relations (ICER) differed

substantially, Ø  Lifetime-perspective was chosen.



Ø Few studies have assessed the cost-effectiveness of early prevention (<3 years), majority of studies focussed on USA (Yavuz et al. 2015, Batrick and Reinhold 2010)

Ø Economic evaluation is only based on cost while effects are not included è partial economic evaluation.

Ø Compared to formula, significant cost savings of breastfeeding (€12,6 billion per year if 90% of U.S. women breastfeed) (Batrick and Reinhold 2010)

Need for future studies to assess the cost-effectiveness

of early prevention!



3 major reasons ... Ø Insignificant effect sizes, particularly when looking

at long-term effectiveness. Ø Conventional approaches to evaluate cost-

effectiveness are of limited use given the complexity of childhood obesity and obesogenic environments.

Ø Today´s common practise: Ø Focus on implemention of programs while economic

evaluations are often conducted after programs have been finished => retrospective economic evaluations tend to be imprecise.

Why the lack of economic evaluations?


Urgent need for best-practise toolbox for efficient data acquisition:

1.  Involve health economists in design phase of an intervention:

Since lifetime simulations require the measurement of longer run effects, the conduction of long-run interventions is needed.

Best-practise Guidance


2.  Involve health economists to collect and administer data alongside the trial e.g. design of standardised questionnaires to collect primary data Ø Standardised measurement of clinical outcomes

Ø However, good economic evaluations require other outcomes like well-being (children?)

Ø Measurement of cost is still a major concern Ø Development of a cost tool is need

(standardised measurement of direct and indirect cost before, during and after intervention)



3.  Conduction of pilot program; adaption of questionaires if necessary

4.  Health economic monitoring and assessment of intervention

Ø Selection of parameter that measure effects? Ø  Interpretation of health-economic results? Ø Validity (internal/external) of results? Ø Policy recommendations?



Economic Evaluation Process D

esig

n Im

plem

enta

tion

Design of intervention and construction of questionaire(s)

Intervention

Direct medical and non-medical cost Indirect cost

Effects

Validity? Generalisability?

ICER: Δ KA – Δ KB Δ EA – Δ EB





4.  Conclusions

Overview


Conclusions

Ø  Transitions between overweight and obesity are particularly high in early childhood è early childhood seems crucial for preventive programs.

Ø Coordinate efforts between intervention developers, health care specialists and health economists in an effective fashion.

Ø Common use of best-practise toolbox for efficient data acquisition.


• Bartick M., Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis, Pediatrics 2010; 125: e1048-56. • Doering N., Mayer S., Rasmussen F., Sonntag D. Economic evaluation of obesity prevention in early childhood: methods, limitations and recommendations, 2016, forthcoming International Journal of Environmental Research and Public Health, special issue Economics of Prevention and Treatment of Obesity. • Fröschl B, Wirl C, Haas S. Overweight prevention in adolescents and children (behavioural and environmental prevention). GMS Health Technol Assess 2009; 5: Doc05. • Galani C, Schneider H: Effectiveness of preventive and therapeutic interventions in overweight and obesity - A health technology assessment. In: Gesundheit Bf, (ed.). Basel: Health Econ AG 2006. • Heckman J. Skill formation and the economics of investing in disadvantaged children. Science 2006; 312: 1900-1902. • Konnopka A, Bodemann M, Koenig HH. Health burden and costs of obesity and overweight in Germany. Eur J Health Econ 2011; 12: 345-52. • Robert Koch Institute (RKI). The German Health Survey for Children and Adolescents 2003-2006. Public Use File 4. Version. http://dx.doi.org/10.7797/9-200306-1-1-4, 2013. • Singh AS, Mulder C, Twisk JW, van Mechelen W, Chinapaw MJ. Tracking of childhood overweight into adulthood. A systematic review of the literature. Obes Rev 2008; 9: 474-488.

Literature (I)


• Sonntag D, Ali S, Lehnert T, Konnopka A, Riedel-Heller S, Koenig HH. Modeling the lifetime cost of child obesity in Germany, Pediatric Obesity 2015. • Sonntag D, Ali S, deBock F. Lifetime indirect cost of childhood overweight and obesity: a decision analytic model, forthcoming Obesity 2016. • Trasande L. How much should we invest in preventing childhood obesity? Health Affairs 2010, 372-378. • von Lengerke T, John J, Mielck A, et al. Excess direct medical costs of severe obesity by socioeconomic status in German adults. Psycho-social medicine 2010;7. • von Lengerke T, Krauth C. Economic costs of adult obesity: a review of recent European studies with a focus on subgroup-specific costs. Maturitas 2011, 69: 220-229. • Wolfenstetter SB. Future direct and indirect costs of obesity and the influence of gaining weight: results from the MONICA/KORA cohort studies, 1995-2005. Econ Hum Biol 2012;10: 127-138. • Yang Z, Hall AG. The financial burden of overweight and obesity among elderly Americans: The dynamics of weight, longevity, and health care cost. Health Serv Res Suppl 2008; 43: 849-868. • Yavuz H, Ijzendoorn M, Mesman J, van der Veek S. Interventions aimed at reducing obesity in early childhood: a meta-analysis of programs that envolve parents. Journal of Child Psychology and Psychiatry, 2015, 677-692.

Literature (II)


Thanks a lot for your attention!


Additional Slides


Is childhood overweight and obesity a concern?

Ø  Prevalence of overweight and obesity has nearly doubled in the last 20 years.

Ø  In Europe: substantial increase over the last decade Ø  In Germany (based on KiGGS; children aged 3-16 years):

6.2% overweight 2.9% obese

Ø  Probability to have excess weight…

(Singh et al., Obesity Review 2008):

is the higher, the higher the weight during childhood. Relative risk of children: appr. 2-10

Ø  30% of obese adults were obese as child


1. Obesity tracking from child- to adulthood

• Cohort is starting in age of 3 towards 17

• Markov cycle: 1 year

• Mortality rates are used from Federal Statistical Office

• Model additionally considers whether a child was normal weight or overweight before tracking into the next stage



2. Estimation of transition probabilities

• Kinder- und Jugendgesundheitssurvey (KiGGS): cross-sectional data

- Adapting of health states “Normal weight“, “Overweight“ and “Obese”

- Since data are not available for each year, data are adjusted by linear regressions

- Determination of age- and gender-specific transition probabilities




ADULTS (Age: 18-75)






NORMAL_post overweight/obese

DEATH

OVERWEIGHT_post overweight/obese

OBESE_post obese

tpDeath_ * rr-adult_o * rr_child_a

tpDeath_ * rr_adult_a * rr_child_a

tp_adult__no

tp_adult_oa tp_adult_ao

tp_adult__on



Calculation of transition probabilities

where represents the prevalence of BMI category i at the age t+1, represents the prevalence of BMI category i at age t and represents the prevalence of BMI category j at age t.

( ), 1i tP BMI +

( ),i tP BMI

( ),j tP BMI

, 1 ,

,

( ) ( ) with ,

( )i t i t

jij t

P BMI P BMIj i

P BMIα + −

= ≠ (1)


Calculation of transition probabilities

where represents the prevalence of BMI category i at the age t+1, denotes the prevalence of BMI category i at age t.

, , 1

,

( ) ( ),

( )i t i t

ii t

P BMI P BMIP BMI

α +−=

( ), 1i tP BMI +

( ),i tP BMI

(2)


Pubmed752 EconLit

147 Googlescholar10,042 Cochrane

12 Interna>onal J. of Obesity

33 Obesity184 NHSEED

16 Public Health30

632 poten>al papers included into abstract review

10,584 papers excluded by >tle review

406 papers excluded by abstract review

226 poten>al papers included into full considera>on

58 German papers included into full-‐text review

-‐ 125 papers excluded due to non-‐German studies-‐ 43 papers excluded due to duplicates

6 papers included

52 papers excluded due to:-‐ 4 papers were systema>c review without providing cost informa>on-‐ 2 papers were focus on direct cost analysis-‐ 6 papers provided no economical data or indirect cost data-‐ 40 papers excluded due to irrelevant study informa>on


Reference Site/Population size/Age Method Key Findings

Wolfenstetter et al. (2012)

Augsburg, 2581, 25-65y Two-part regression model

The average total indirect cost per person for those who stayed at the same BMIclass were €2,136 (Normalweight: 18.5<BMI<25), €2,909 (Overweight: 25<BMI<30)and €2,614 (Obese:BMI>30). An overweight person who becomes obese incuredcosts of €3,381 whereas an normalweight person who becomes overweight incuredcosts of €2,473.

Breitfelder et al. (2011)

Munich, Wesel, Bad Honnef and Leipzig, 3,508, 9-<12y

Two-part regression model

Mean annual indirect costs were €100 (Normalweight: P10-P90), €85 (Overweight:>P90 to P97) and €118 ( Obese>P97).

Konnopka et al. (2011) Germany, 15->90y

Population-Attributable Fraction

(PAF)

Obesity causes €5,019 million in indirect costs, of which €646 million were due tosick absence, €992 million were due to earliy retirement and €3,381 million weredue to morality.

Sander and Bergemann

(2003)Germany, ≥ 25y

Attributable Proportion in the

population (APpop)

Obesity causes €328 million in indirect costs, of which €150 million were due towork loss, €112 million were due to disability and €67 million were due to mortality.

Bödemann (2010) Germany, 15-90yPopulation-

Attributable Fraction (PAF)

Obesity causes €3,981 million in indirect costs, of which €504 million were due tosick absence, €605 million were due to early retirement, €2,710 million were due tomorality and €160 million were due to rehabilitation.

Knoll and Hauner (2008) Germany, 15-65y

Population-Attributable Fraction

(PAF)

Obesity cause €1,655 million direct cost, of which €582 million were due to disability, €760 million were due to inability to work and €313 million were due to mortality.


3. Further data

• Prevalence data are used from the Microcensus 2009

• Mortality rates are used from Federal Statistical Office

•  In order to determine relative risks (RRs) two literature reviews have been conducted: -  Age-specific mortality RR associated with obesity or

overweight are used from the European Prospective Investigation into Cancer and Nutrition (EPIC-Study) -  Adult mortality RR associated with obesity or overweight

in childhood used from Adami (2008)



2. Costs

• systematic literature search (four electronic data bases, i.e., Medline, EconLit, National Health Service’s Economic Evaluation database (NHS EED), and the Cochrane Library).

• key terms “presenteeism”, “absenteeism”, “indirect costs” with “overweight”, “obesity” and “Germany”.



Lifetime costs of overweight and obesity

0

1,000

2,000

3,000

4,000

5,000

6,000

18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 72 74 76 78 80

Cumulative excess costs (million €)

Age

high SES (obesity) high SES (overweight) middle SES (obesity)

middle SES (overweight) low SES (obesity) low SES (overweight)


Comparison with other COI-studies Sonntag et al. 2015a, 2016

Fernandes 2009

Brunello 2009 lifetime cost until age 55

Germany USA Europe

Proxy for incidence

Proxy incidence Incidence-based (long. Data SHARE)

Markov Model Monte-Carlo Sim., lifetable

Micro-simulation

Direct cost m 2.99 4.9 1.37

f 3.37 3.5

Indirect cost m 2.94 -----

f 3.85 -----

Excess direct lifetime cost (discount 3%)

€4,262-7,028

$18.999-$26.775

13,840 for obese versus non-obese in adulthood

Excess indirect lifetime cost (discount 3%)

€2,445 – 4,209



Fernandes 2010


Germany USA Europe

Proxy for incidence



Micro-simulation


f 3.37 3.5


f 3.85 -----


€4,262-7,028

$18,999-$26,775



€2,445 – 4,209


Ø  Today´s common practise: Ø Focus on implemention of programs while economic

evaluations are often conducted after programs have been finished => retrospective economic evaluations tend to be imprecise.

Ø Conduction of full economic evaluations of early prevention is patchy (most economic evaluations focus on costs while long-run effects are not measured).

Ø How can we interpret results of economic evaluations? Are the results valid?

Why the lack of economic evaluations?

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