The Use of Precision Epigenetic Methods for the Diagnosis and Care of Stable Coronary Heart Disease Reduces Healthcare Costs.

INTRODUCTION: The cost of secondary prevention of coronary heart disease (CHD) is continuing to increase, with a substantial portion of this acceleration being driven by the expense of confirmatory diagnostic testing. Conceivably, newly developed precision epigenetic technologies could drive down these costs. However, at the current time, their impact on overall expense for CHD care is poorly understood. We hypothesized that the use of a newly developed, highly sensitive, and specific epigenetic test, PrecisionCHD, could decrease the costs of secondary prevention. METHODS: To test this hypothesis, we constructed a budget impact analysis using a cost calculation model that examined the effects of substituting PrecisionCHD for conventional CHD diagnostic tests on the expenses of the initial evaluation and first year of care of stable CHD using a 1-year time horizon with no discounting. RESULTS: The model projected that for a commercial insurer with one million members, full adoption of PrecisionCHD as the primary method of initial CHD assessment would save approximately $113.6 million dollars in the initial year. CONCLUSION: These analyses support the use of precision epigenetic methods as part of the initial diagnosis and care of stable CHD and can meaningfully reduce cost. Real-world pilots to test the reliability of these analyses are indicated.

Perceptions of the Right to Food Among Adults Aged 60 Years and Older.

This study explores perceptions of the right to food and issues around food assistance and access among older adults. We conducted 20 semi-structured interviews with adults aged 60+ in Iowa, half of whom were food insecure. Most respondents expressed the right to food concerns freedom of choice rather than physical and financial access. The respondents said poor food access was due to improper choices or not accessing food assistance. While respondents believed food insecurity was morally wrong, they also believed current food assistance services are sufficient. These results have important implications for understanding how older adults think about food access.

Have States Reduced Obesity by Legislating More Physical Activity in Elementary School?

Policy Points Between 1998 and 2016, 24 states and the District of Columbia passed laws meant to increase the time that children spent in physical education (PE) or other school-based physical activity (PA). Schools largely disregarded changes to PE/PA laws, which did not increase the time that children spent in PE or recess and did not reduce body mass index, overweight, or obesity. Closer oversight of schools would be needed to improve compliance with state PE and PA laws. Yet, even with better compliance, we estimate that PE and PA policies would be inadequate to reverse the obesity epidemic. Policies should also address consumption, both inside and outside of school. CONTEXT: To control childhood obesity, leading medical organizations have recommended increasing the time that children spend in physical education (PE) and other school-based physical activity (PA). Yet, it is unknown how many states have passed laws that codify these recommendations, and it is unknown what effect changing state laws has had on obesity or the time that children actually spent in PE and PA. METHODS: We joined state laws to national samples of 13,920 children from two different cohorts of elementary students. One cohort attended kindergarten in 1998; the other attended kindergarten in 2010; both cohorts were followed from kindergarten through fifth grade. We estimated the effects of changes to state laws in a regression with state and year fixed effects. FINDINGS: Twenty-four states and the District of Columbia increased the time that children were recommended or required to spend in PE or PA. These changes in state policies did not increase actual time spent in PE or recess, did not affect average body mass index (BMI) or BMI Z score, and did not affect the prevalence of overweight or obesity. CONCLUSION: Increasing the PE or PA time required or recommended by state laws has not slowed the obesity epidemic. Many schools have failed to comply with state laws. A back-of-the-envelope calculation suggests that, even with better compliance, the legislated changes in PE laws might not have changed energy balance enough to reduce obesity prevalence.

A Qualitative Study of Factors Influencing Food Choices and Food Sources Among Adults Aged 50 Years and Older During the Coronavirus Disease 2019 Pandemic.

BACKGROUND: The coronavirus disease 2019 pandemic affected food availability and accessibility for many older adults, especially those experiencing food insecurity. Food citizenship is a theoretical framework that encourages the use of alternate over industrial food sources and can characterize where foods are acquired and how food choices are made. OBJECTIVE: The purpose of this study is to explore how Iowans aged 50 years and older made choices about what foods to acquire and where to acquire foods during the coronavirus disease 2019 pandemic using food citizenship as a theoretical framework. DESIGN: We used in-depth interviews with Iowans aged 50 years and older (N = 60). PARTICIPANTS: We recruited respondents through Area Agencies on Aging, food banks, and food pantries. Individuals who contacted the research team, were aged 50 years and older, and spoke English were eligible. Half of the sample screened as food insecure. STATISTICAL ANALYSIS: We conducted a thematic analysis to identify recurring themes. RESULTS: Food costs, personal preferences, and the healthfulness of food were cited as the most influential factors. Respondents said that the pandemic had not changed how they make choices, but increased prices had made costs more salient. Respondents primarily got their food from industrial food retailers, government programs, or food pantries. More than half of the respondents also acquired food from an alternate food source, such as a farmers' market. Reasons for not using alternate food sources included cost and transportation barriers. CONCLUSIONS: It is essential to ensure that older adults have access to affordable, healthy foods, especially during crises such as the coronavirus disease 2019 pandemic. Alternate food sources provided supplementary, healthy food for many respondents, but there are opportunities to expand the use of these food sources. Incentivizing the use of alternate food sources through government programs and connecting the emergency food system to local producers could increase the consumption of healthy food.

The Relationship between Political, Economic, Social, and Cultural Vulnerability and Food Insecurity among Adults Aged 50 Years and Older.

Individuals experience food insecurity when they worry about or have limited access to nutritious foods. Food insecurity negatively impacts older adults' health. Social exclusion is a theoretical framework describing how unequal access to rights, resources, and capabilities results in political, economic, social, and cultural vulnerability, which leads to health disparities. We used the Health and Retirement Study to cross-sectionally examine associations between vulnerability and experiencing food insecurity in adults 50 years and older using the social exclusion framework. We tested the association between experiencing food insecurity and indicators of political, economic, social, and cultural vulnerability using logistic regression controlling for demographic and health-related factors. Analyses were performed with all respondents and sub-group of respondents with incomes less than 400% of the federal poverty level (FPL). Assets (OR = 0.97 in both samples), income (OR = 0.85, 0.80 in 400% FPL sub-sample), perceived positive social support from other family (OR = 0.86, 0.84 in 400% FPL sub-sample), and perceived everyday discrimination (OR = 1.68, 1.82 in 400% FPL sub-sample) were significantly associated with food insecurity. Perceived positive social support from spouses, children, or friends and U.S. citizenship status were not significantly associated with food insecurity. Further research is needed to define and measure each dimension of vulnerability in the social exclusion framework. Interventions and policies designed to prevent food insecurity should address these vulnerabilities.

Cost-utility analysis of an integrated genetic/epigenetic test for assessing risk for coronary heart disease.

Aim: New epigenetically based methods for assessing risk for coronary heart disease may be more sensitive but are generally more costly than current methods. To understand their potential impact on healthcare spending, we conducted a cost-utility analysis. Methods: We compared costs using the new Epi + Gen CHD™ test with those of existing tests using a cohort Markov simulation model. Results: We found that use of the new test was associated with both better survival and highly competitive negative incremental cost-effectiveness ratios ranging from -$42,000 to -$8000 per quality-adjusted life year for models with and without a secondary test. Conclusion: The new integrated genetic/epigenetic test will save money and lives under most real-world scenarios. Similar advantages may be seen for other epigenetic tests.

Oakland's sugar-sweetened beverage tax: Impacts on prices, purchases and consumption by adults and children.

Several cities in the U.S. have implemented taxes on sugar-sweetened beverages (SSBs) in an attempt to improve public health and raise revenue. On July 1, 2017, Oakland introduced a tax of one cent per ounce on SSBs. In this paper, we estimate the impact of the tax on retail prices, product availability, purchases, and child and adult consumption of taxed beverages in Oakland, as well as of potential substitute beverages. We collected data from Oakland stores and their customers and a matched group of stores in surrounding counties and their customers. We collected information in the months prior to the implementation of the tax and again a year later on: (1) prices, (2) purchase information from customers exiting the stores, and (3) a follow-up household survey of adults and child beverage purchases and consumption. We use a difference-in-differences identification strategy to estimate the impact of the tax on prices, purchases, and consumption of taxed beverages. We find that roughly 60 percent of the tax was passed on to consumers in the form of higher prices. There was a slight decrease in the volume of SSBs purchased per shopping trip in Oakland and a small increase in purchases at stores outside of the city, resulting in a decrease in purchases of 11.33 ounces per shopping trip that is not statistically significant. We find some evidence of increased shopping by Oakland residents at stores outside of the city. We do not find evidence of substantial changes in the overall consumption of SSBs or of added sugars consumed through beverages for either adults or children after the tax.

The impact of sugar-sweetened beverage taxes on purchases: Evidence from four city-level taxes in the United States.

Since 2017, many US cities have implemented taxes on sugar-sweetened beverages to decrease consumption of sugary beverages and raise revenue. We analyze household receipt data to examine the impact of taxes on households' beverage purchases in the four largest US cities with such taxes: Philadelphia, PA; San Francisco, CA; Seattle, WA; and Oakland, CA. We compare changes in monthly household purchases in the treatment cities with changes in two comparison groups: (1) areas adjacent to the treatment cities or (2) a matched set of households nationally. An increase in the tax rate of 1 cent per ounce decreases household purchases of taxed beverages by 53.0 ounces per month (12.2%). This impact is consistent with a reduction in individual consumption of 5 calories per day per household member and eventual reduction in weight of 0.5 pounds. However, the decline was concentrated in Philadelphia, where the tax decreased purchases by 27.7%. There was no change in purchases of taxed beverages in the other three cities combined.

The impact of the Philadelphia beverage tax on purchases and consumption by adults and children.

Numerous U.S. cities have recently enacted taxes on sweetened beverages. To examine the effects of the beverage tax of 1.5 cents per ounce in Philadelphia, we surveyed adults and children in Philadelphia and nearby comparison communities both before the tax and nearly one year after implementation. We find that the tax reduced purchases in Philadelphia stores and that Philadelphia residents increased purchases of taxed beverages outside of the city. The tax reduced the frequency of adults' soda consumption by 31 percent, but had no detectable impacts on adults' consumption of other beverages. The tax had no detectable impact on children's consumption of soda or all taxed beverages, although children who were frequent consumers prior to the tax reduced their consumption after the tax.

The Economics of Taxes on Sugar-Sweetened Beverages: A Review of the Effects on Prices, Sales, Cross-Border Shopping, and Consumption.

During the past decade, dozens of countries, regions, and cities have enacted taxes on sugar-sweetened beverages (SSBs). They have been primarily motivated by a desire to raise prices, reduce sales and consumption, improve population health, and raise revenue. This review outlines the economic rationale for SSB taxes and illustrates their predicted effects. It reviews the research on the effects of these taxes on retail prices, sales, cross-border shopping, consumption, and product availability. The evidence indicates that the amount by which taxes increase retail prices (also called the pass-through of the tax) varies by jurisdiction, ranging from less than 50% to 100% of the tax. Sales tend to decrease significantly in the taxing jurisdiction, although this seems to be partly offset by residents increasingly shopping outside of the taxing jurisdiction (i.e., engaging in cross-border shopping).Overall, taxes lower consumption of the taxed beverages by adults, although not for all types of beverages or all groups of consumers. We conclude with suggestions for improving the design of such taxes and directions for future research.

The impact of expanding Medicaid on health insurance coverage and labor market outcomes.

Expansions of public health insurance have the potential to reduce the uninsured rate, but also to reduce coverage through employer-sponsored insurance (ESI), reduce labor supply, and increase job mobility. In January 2014, twenty-five states expanded Medicaid as part of the Affordable Care Act to low-income parents and childless adults. Using data from the 2011-2015 March Current Population Survey Supplements, we compare the changes in insurance coverage and labor market outcomes over time of adults in states that expanded Medicaid and in states that did not. Our estimates suggest that the recent expansion significantly increased Medicaid coverage with little decrease in ESI. Overall, the expansion did not impact labor market outcomes, including labor force participation, employment, and hours worked.

The Relationship between the School Breakfast Program and Food Insecurity.

Food insecurity rates have risen significantly in the United States beginning with the recent recession and remained high. The implications of these high rates are severe in that food insecurity has been associated with a wide range of health, behavioral, social and cognitive difficulties. This paper examines the relationship between the School Breakfast Program (SBP) and food insecurity outcomes. The SBP has the potential to reduce food insecurity because of the direct provision of breakfast to students and the implied income transfer to households. We use state-level cutoffs tied to school-level poverty rates that mandate the provision of the SBP to compare the food security outcomes of students in similar schools, but with different requirements to provide breakfast. Our estimates suggest that state policies requiring schools to offer the SBP have reduced food insecurity for young children.

Nutrition and Cognitive Achievement: An Evaluation of the School Breakfast Program.

This paper investigates the impact of the School Breakfast Program (SBP) on cognitive achievement. The SBP is a federal entitlement program that offers breakfast to any student, including free breakfast for any low-income student, who attends a school that participates in the program. To increase the availability of the SBP, many states mandate that schools participate in the program if the percent of free or reduced-price eligible students in a school exceeds a specific threshold. Using the details of these mandates as a source of identifying variation, I find that the availability of the program increases student achievement.

Obesity is associated with an increase in pharmaceutical expenses among university employees.

OBJECTIVE: To examine costs associated with obesity in an employee population and factors associated with increased costs. METHODS: We used data from the Physical Activity and Life Style (PALS) study, a randomized prospective design evaluating three interventions to increase physical activity among physically inactive nonfaculty university employees (n = 454). The primary exposure variable, obesity (measured by body mass index), was obtained from the in-person baseline survey. Covariates were obtained from the baseline survey and included demographic characteristics and health status. Data from the baseline survey was linked with administrative data to determine pharmaceutical, inpatient, outpatient, and total health care costs for three years. Average monthly expenditures for obese and nonobese individuals were compared using t-tests and a two-part multivariate regression model adjusted for demographic and socioeconomic characteristics and health behaviors. RESULTS: Although in-patient and outpatient expenses were not associated with obesity, pharmaceutical expenditures were $408 or 87.2% higher per year ($468 versus $876) for obese individuals than for nonobese individuals, which reflected poorer health behaviors and health status of obese adults. CONCLUSION: Awareness of the costs associated with obesity among employees can stimulate employers to make the investment in providing employer-sponsored wellness and health improvement programs to address obesity.

Non-linear effects of soda taxes on consumption and weight outcomes.

The potential health impacts of imposing large taxes on soda to improve population health have been of interest for over a decade. As estimates of the effects of existing soda taxes with low rates suggest little health improvements, recent proposals suggest that large taxes may be effective in reducing weight because of non-linear consumption responses or threshold effects. This paper tests this hypothesis in two ways. First, we estimate non-linear effects of taxes using the range of current rates. Second, we leverage the sudden, relatively large soda tax increase in two states during the early 1990s combined with new synthetic control methods useful for comparative case studies. Our findings suggest virtually no evidence of non-linear or threshold effects.

The effect of school quality on black-white health differences: evidence from segregated southern schools.

This study assesses the effect of black-white differences in school quality on black-white differences in health in later life resulting from the racial convergence in school quality for cohorts born between 1910 and 1950 in southern states with segregated schools. Using data from the 1984-2007 National Health Interview Surveys linked to race-specific data on school quality, we find that reductions in the black-white gap in school quality led to modest reductions in the black-white gap in disability.

The impact of physical education on obesity among elementary school children.

In response to the dramatic rise in childhood obesity, the Centers for Disease Control (CDC) and other organizations have advocated increasing the amount of time that elementary school children spend in physical education (PE) classes. However, little is known about the effect of PE on child weight. This paper measures that effect by instrumenting for child PE time with the state's mandated minimum number of minutes of PE, using data from the Early Childhood Longitudinal Study, Kindergarten Cohort (ECLS-K) for 1998-2004. Results from IV models indicate that PE lowers BMI z-score and reduces the probability of obesity among 5th graders. This effect is concentrated among boys; we find evidence that this gender difference is partly attributable to PE being a complement with other physical activity for boys, whereas they are substitutes for girls. This represents some of the first evidence of a causal effect of PE on youth obesity, and thus offers at least some support for the assumptions behind the CDC recommendations. We find no evidence that increased PE time crowds out time in academic courses or has spillovers to achievement test scores.

School quality and the education-health relationship: evidence from blacks in segregated schools.

In this paper, we estimate the effect of school quality on the relationship between schooling and health outcomes using the substantial improvements in the quality of schools attended by black students in the segregated southern states during the mid-1900s as a source of identifying variation. Using data from the National Health Interview Survey, our results suggest that improvements in school quality, measured as the pupil-teacher ratio, average teachers' wage, and length of the school year, amplify the beneficial effects of education on several measures of health in later life, including self-rated health, smoking, obesity, and mortality.