The Long-term Value of Bariatric Surgery Interventions for American Adults With Type 2 Diabetes Mellitus.

BACKGROUND: Bariatric surgery can cause type 2 diabetes (diabetes) remission for individuals with comorbid obesity, yet utilization is <1%. Surgery eligibility is currently limited to body mass index (BMI) ≥35 kg/m 2 , though the American Diabetes Association recommends expansion to BMI ≥30 kg/m 2 . OBJECTIVE: We estimate the individual-level net social value benefits of diabetes remission through bariatric surgery and compare the population-level effects of expanding eligibility alone versus improving utilization for currently eligible individuals. METHODS: Using microsimulation, we quantified the net social value (difference in lifetime health/economic benefits and costs) of bariatric surgery-related diabetes remission for Americans with obesity and diabetes. We compared projected lifetime surgical outcomes to conventional management at individual and population levels for current utilization (1%) and eligibility (BMI ≥35 kg/m 2 ) and expansions of both (>1%, and BMI ≥30 kg/m 2 ). RESULTS: The per capita net social value of bariatric surgery-related diabetes remission was $264,670 (95% confidence interval: $234,527-294,814) under current and $227,114 (95% confidence interval: $205,300-248,928) under expanded eligibility, an 11.1% and 9.16% improvement over conventional management. Quality-adjusted life expectancy represented the largest gains (current: $194,706; expanded: $169,002); followed by earnings ($51,395 and $46,466), and medical savings ($41,769 and $34,866) balanced against the surgery cost ($23,200). Doubling surgical utilization for currently eligible patients provides higher population gains ($34.9B) than only expanding eligibility at current utilization ($29.0B). CONCLUSIONS: Diabetes remission following bariatric surgery improves healthy life expectancy and provides net social benefit despite high procedural costs. Per capita benefits appear greater among currently eligible individuals. Therefore, policies that increase utilization may produce larger societal value than expanding eligibility criteria alone.

Improving Diet Quality in U.S. Adults: A 30-Year Health and Economic Impact Microsimulation.

INTRODUCTION: Epidemiologic studies relating health outcomes to dietary patterns captured by diet quality indices have shown better quality scores associated with lower mortality and chronic disease incidence. However, changing chronic disease risk factors only alters population health over time, and initial diet quality systematically varies across the population by sociodemographic status. This study uses microsimulation to examine 30-year impacts of improved diet quality by sociodemographic group. METHODS: Diet quality across 12 sex-, race/ethnicity-, and education-defined subgroups was estimated from the 2011-2012 National Health and Nutrition Examination Survey. In 2021, the Future Adults (dynamic microsimulation) Model was used to simulate population health and economic outcomes over 30 years for these subgroups and all adults. The modeled pathway was through lowering risk for heart disease by following U.S. Dietary Guidelines. RESULTS: Diet quality varied across the sociodemographic subgroups, and half of U.S. adults had diet quality that would be classified as poor. Improving U.S. diet quality to that reported for the top 20% in 2 large health professionals' samples could reduce incidence of heart disease by 9.9% (7.6%-13.8% across the 12 sociodemographic groups) after 30 years. Year 30 would also have 37,000 fewer deaths, 694,000 more quality-adjusted life years, and healthcare cost savings of $59.6 billion (2019 U.S. dollars). CONCLUSIONS: Dynamic microsimulation enables predictions of socially important outcomes of prevention efforts, most of which are many years in the future and beyond the scope of trials. This paper estimates the 30-year population health and economic impact of poor diet quality by sociodemographic group.

Depressive Symptoms among US Adults during the Great Recession and Economic Recovery.

BACKGROUND AND AIMS: We study the trajectory of depressive symptoms among US adults before, during, and after the 2008/2009 Great Recession. METHODS: We use repeated cross-sectional surveys of the National Health and Nutrition Examination Survey (NHANES) between 2005 and 2018. Mental health is assessed with the Patient Health Questionnaire-9 (PHQ-9), with the following categorization for depressive symptoms: none or mild (score 0-9), moderate or severe (score 10-27). A parallel time series was calculated from the Behavioral Risk Factor Surveillance System (BRFSS) on self-reported number of days with poor mental health. RESULTS: NHANES data show a statistically significant increase in depressive symptoms from 2005/2006 to 2007/2008 (the beginning of the Great Recession), but there were no significant or consistent changes after 2007/2008. In particular, the deterioration in the adjusted predicted PHQ-9 scores occurred prior to the large increase in unemployment rate (2009/2010). As the macroeconomic situations improved and unemployment rates recovered, mental health did not return to the previous level. In the latest wave of NHANES (2017/2018), unemployment rates were at the lowest level over the analysis period; however, the adjusted predicted PHQ-9 scores were higher than that at the beginning of the Great Recession. Trends of PHQ-9 scores were similar across income groups - all groups had an increase in depressive symptoms after 2005/2006 and PHQ-9 scores were still high in 2017/2018 after controlling for sociodemographic status. Group with the lowest income had higher levels of depressive symptoms at every time point. BRFSS data shows no consistent changes in the number of days with poor mental health that parallel economic conditions. DISCUSSION: Depressive symptoms at the population level did not match the economic cycle before, during and after the Great Recession. Future research is needed to better understand the lack of correlation between population mental health and macroeconomic conditions.

Microsimulation projections of obesity interventions on cardiometabolic health disparities in the United States.

OBJECTIVE: The aim of this study was to estimate long-term impacts of health education interventions on cardiometabolic health disparities. METHODS: The model simulates how health education implemented in the United States throughout 2019 to 2049 would lead to changes in adult BMI and consequent hypertension and type 2 diabetes. Health outcome changes by sex, racial/ethnic (non-Hispanic White, non-Hispanic Black, and Hispanic), and weight status (normal: 18.5 ≤ BMI < 25; overweight: 25 ≤ BMI < 30; and obesity: 30 ≤ BMI) subpopulations were compared under a scenario with and one without health education. RESULTS: By 2049, the intervention would reduce average BMI of women with obesity to 27.7 kg/m2 (CI: 27.4-27.9), which would be 2.9 kg/m2 lower than the expected average BMI without an intervention. Education campaigns would reduce type 2 diabetes prevalence, but it would remain highest among women with obesity at 27.7% (CI: 26.2%-29.2%). The intervention would reduce hypertension prevalence among White women by 4.7 percentage points to 38.0% (CI: 36.4%-39.7%). For Black women in the intervention, the 2049 hypertension prevalence would be 52.6% (CI: 50.7%-54.5%). Results for men and women were similar. CONCLUSIONS: Long-term health education campaigns can reduce obesity-related disease. All population groups benefit, but they would not substantially narrow cardiometabolic health disparities.

Diet Quality in the United States Improved during the Great Recession and Deteriorated During Economic Recovery.

BACKGROUND: Macroeconomic changes are associated with population health outcomes, such as mortality, accidents, and alcohol use. Diet quality is a risk or protective factor that could be influenced by economic conditions. OBJECTIVE: This study examined the trajectory of diet quality measured by the Healthy Eating Index 2015 before, during, and after the 2008-2009 Great Recession. DESIGN: Repeated cross-sectional survey data from the National Health and Nutrition Examination Survey were analyzed. PARTICIPANTS/SETTING: The analytic sample included 48,679 adults who completed at least one dietary recall from National Health and Nutrition Examination Survey 1999-2018. MAIN OUTCOME MEASURES: Diet quality was assessed with a 24-hour dietary recall to calculate the Healthy Eating Index 2015 total scores, a measure of the conformance with the 2015-2020 Dietary Guidelines for Americans. STATISTICAL ANALYSES PERFORMED: Least squares regression was used to adjust for demographic changes across waves. RESULTS: Diet quality improved noticeably during the Great Recession and deteriorated as economic conditions improved. CONCLUSIONS: Deteriorating economic circumstances may constrain choices, but that does not necessarily imply a worsening of dietary quality. During the Great Recession, American diets became more consistent with Dietary Guidelines for Americans recommendations, possibly because of a shift toward food prepared at home instead of prepared food bought away from home.

Diet quality improvement and 30-year population health and economic outcomes: a microsimulation study.

OBJECTIVE: Diets closer aligned with nutritional guidelines could lower the risk of several chronic conditions and improve economic outcomes, such as employment and healthcare costs. However, little is known about the range, order of magnitude and timing of these potential effects. DESIGN: We used a microsimulation approach to predict US population changes over 30 years in health and economic outcomes that could result from a substantial (but not impossible) improvement in diet quality - an improvement from the third to the fifth quintile of US scores on the Alternate Healthy Eating Index, 2010 version. SETTING: Risk ratios from the literature for diabetes, heart disease and stroke were used to modify the Future Adult Model (FAM) to simulate outcomes from a higher-quality diet. Model parameter uncertainty was assessed using bootstrap and sensitivity analysis examined the variation in published risk ratios. PARTICIPANTS: FAM simulates outcomes for the US adult population aged 25 and older. RESULTS: Improved diet quality initially leads to very small changes in chronic disease prevalence, but these accumulate over time. If diets improved beginning in 2019, after 30 years diabetes prevalence could be reduced by 5·9 million cases (11·5 %), heart disease prevalence by 4·0 million cases (7·2 %) and stroke prevalence by 1·9 million cases (10·3 %). These reductions in disease prevalence would be accompanied that same year by fewer deaths (88 000) and healthcare cost savings of $144·0 billion (2019 USD). CONCLUSIONS: This microsimulation study suggests that improvements in diet are likely to improve health and economic population outcomes over time.

A Cash-back Rebate Program for Healthy Food Purchases in South Africa: Selection and Program Effects in Self-reported Diet Patterns.

OBJECTIVES: A South African insurer launched a rebate program for healthy food purchases for its members, but only available in program-designated supermarkets. To eliminate selection bias in program enrollment, we estimated the impact of subsidies in nudging the population towards a healthier diet using an instrumental variable approach. METHODS: Data came from a health behavior questionnaire administered among members in the health promotion program. Individual and supermarket addresses were geocoded and differential distances from home to program-designated supermarkets versus competing supermarkets were calculated. Bivariate probit and linear instrumental variable models were performed to control for likely unobserved selection biases, employing differential distances as a predictor of program enrollment. RESULTS: For regular fast-food, processed meat, and salty food consumption, approximately two-thirds of the difference between participants and nonparticipants was attributable to the intervention and one-third to selection effects. For fruit/ vegetable and fried food consumption, merely one-eighth of the difference was selection. The rebate reduced regular consumption of fast food by 15% and foods high in salt/sugar and fried foods by 22%- 26%, and increased fruit/vegetable consumption by 21% (0.66 serving/day). CONCLUSIONS: Large population interventions are an essential complement to laboratory experiments, but selection biases require explicit attention in evaluation studies conducted in naturalistic settings.

Impact of a patient incentive program on receipt of preventive care.

OBJECTIVES: Patient financial incentives are being promoted as a mechanism to increase receipt of preventive care, encourage healthy behavior, and improve chronic disease management. However, few empirical evaluations have assessed such incentive programs. STUDY DESIGN: In South Africa, a private health plan has introduced a voluntary incentive program which costs enrollees approximately $20 per month. In the program, enrollees earn points when they receive preventive care. These points translate into discounts on retail goods such as airline tickets, movie tickets, or cell phones. METHODS: We chose 8 preventive care services over the years 2005 to 2011 and compared the change between those who entered the incentive program and those that did not. We used multivariate regression models with individual random effects to try to address selection bias. RESULTS: Of the 4,186,047 unique individuals enrolled in the health plan, 65.5% (2,742,268) voluntarily enrolled in the incentive program. Joining the incentive program was associated with statistically higher odds of receiving all 8 preventive care services. The odds ratio (and estimated percentage point increase) for receipt of cholesterol testing was 2.70 (8.9%); glucose testing 1.51 (4.7%); glaucoma screening 1.34 (3.9%); dental exam 1.64 (6.3%); HIV test 3.47 (2.6%); prostate specific antigen testing 1.39 (5.6%); Papanicolaou screening 2.17 (7.0%); and mammogram 1.90 (3.1%) (P < .001 for all 8 services). However, preventive care rates among those in the incentive program was still low. CONCLUSIONS: Voluntary participation in a patient incentive program was associated with a significantly higher likelihood of receiving preventive care, though receipt of preventive care among those in the program was still lower than ideal.

Proximity to urban parks and mental health.

BACKGROUND: Urban parks have received attention in recent years as a possible environmental factor that could encourage physical activity, prevent obesity, and reduce the incidence of chronic conditions. Despite long hypothesized benefits of parks for mental health, few park studies incorporate mental health measures. AIMS OF THE STUDY: To test the association between proximity to urban parks and psychological distress. METHODS: Cross-sectional analysis of individual health survey responses. Data were collected for a study of capital improvements of neighborhood parks in Los Angeles. A survey was fielded on a sample of residential addresses, stratified by distance from the park (within 400m, 800m, 1.6 km, and 3.2km; N=1070). We used multiple regression to estimate the relationship between the psychological distress as measured by the MHI-5 (outcome variable) and distance to parks (main explanatory variable), controlling for observed individual characteristics. RESULTS: Mental health is significantly related to residential distance from parks, with the highest MHI-5 scores among residents within short walking distance from the park (400m) and decreasing significantly over the next distances. The number of visits and physical activity minutes are significantly and independently related to distance, although controlling for them does not reduce the association between distance and mental health. DISCUSSION AND LIMITATIONS: This paper provides a new data point for an arguably very old question, but for which empirical data are sparse for the US. A nearby urban park is associated with the same mental health benefits as decreasing local unemployment rates by 2 percentage points, suggesting at least the potential of environmental interventions to improve mental health. The analysis is cross-sectional, making it impossible to control for important confounders, including residential selection. IMPLICATIONS FOR HEALTH POLICY: Mental health policy has traditionally focused on individual-centered interventions. Just as health policy for preventable chronic illnesses has shifted attention to modifiable environmental determinants, population mental health may benefit substantially from environmental interventions. IMPLICATIONS FOR FUTURE RESEARCH: Policy evaluations should incorporate mental health measures when assessing neighborhood improvement programs and physical environments. Many recent and ongoing studies have excluded mental health measure in the belief that they are too burdensome for respondents or irrelevant. If a causal relationship is confirmed, then ameliorating neighborhood conditions and physical environments could represent a scalable way to improve mental health issues for large populations.

Obesity and economic environments.

This review summarizes current understanding of economic factors during the obesity epidemic and dispels some widely held, but incorrect, beliefs. Rising obesity rates coincided with increases in leisure time (rather than increased work hours), increased fruit and vegetable availability (rather than a decline in healthier foods), and increased exercise uptake. As a share of disposable income, Americans now have the cheapest food available in history, which fueled the obesity epidemic. Weight gain was surprisingly similar across sociodemographic groups or geographic areas, rather than specific to some groups (at every point in time; however, there are clear disparities). It suggests that if one wants to understand the role of the environment in the obesity epidemic, one needs to understand changes over time affecting all groups, not differences between subgroups at a given time. Although economic and technological changes in the environment drove the obesity epidemic, the evidence for effective economic policies to prevent obesity remains limited. Taxes on foods with low nutritional value could nudge behavior toward healthier diets, as could subsidies/discounts for healthier foods. However, even a large price change for healthy foods could close only part of the gap between dietary guidelines and actual food consumption. Political support has been lacking for even moderate price interventions in the United States and this may continue until the role of environmental factors is accepted more widely. As opinion leaders, clinicians play an important role in shaping the understanding of the causes of obesity.

Changes in the energy and sodium content of main entrées in US chain restaurants from 2010 to 2011.

BACKGROUND: The food environment shapes individual diets, and as food options change, energy and sodium intake may also shift. Understanding whether and how restaurant menus evolve in response to labeling laws and public health pressures could inform future efforts to improve the food environment. OBJECTIVES: To track changes in the energy and sodium content of US chain restaurant main entrées between spring 2010 (when the Affordable Care Act was passed, which included a federal menu labeling requirement) and spring 2011. DESIGN: Nutrition information was collected from top US chain restaurants' websites, comprising 213 unique brands. Descriptive statistics and regression analysis evaluated change across main entrées overall and compared entrées that were added, removed, and unchanged. Tests of means and proportions were conducted for individual restaurant brands to see how many made significant changes. Separate analyses were conducted for children's menus. RESULTS: Mean energy and sodium did not change significantly overall, although mean sodium was 70 mg lower across all restaurants in added vs removed menu items at the 75th percentile. Changes were specific to restaurant brands or service model: family-style restaurants reduced sodium among higher-sodium entrées at the 75th percentile, but not on average, and entrées still far exceeded recommended limits. Fast-food restaurants decreased mean energy in children's menu entrées by 40 kcal. A few individual restaurant brands made significant changes in energy or sodium, but the vast majority did not, and not all changes were in the healthier direction. Among those brands that did change, there were slightly more brands that reduced energy and sodium compared with those that increased it. CONCLUSIONS: Industry marketing and pledges may create a misleading perception that restaurant menus are becoming substantially healthier, but both healthy and unhealthy menu changes can occur simultaneously. Our study found no meaningful changes overall across a 1-year time period. Longer-term studies are needed to track changes over time, particularly after the federal menu labeling law is implemented.

Does the response to alcohol taxes differ across racial/ethnic groups? Some evidence from 1984-2009 Behavioral Risk Factor Surveillance System.

BACKGROUND: Excessive alcohol use remains an important lifestyle-related contributor to morbidity and mortality in the U.S. and worldwide. It is well documented that drinking patterns differ across racial/ethnic groups, but not how those different consumption patterns would respond to tax changes. Therefore, policy makers are not informed on whether the effects of tax increases on alcohol abuse are shared equally by the whole population, or policies in addition to taxation should be pursued to reach certain sociodemographic groups. AIMS OF THE STUDY: To estimate differential demand responses to alcohol excise taxes across racial/ethnic groups in the U.S. METHODS: Individual data from the Behavioral Risk Factor Surveillance System 1984-2009 waves (N= 3,921,943, 39.3% male; 81.3% White, 7.8% African American, 5.8% Hispanic, 1.9% Asian or Pacific Islander, 1.4% Native American, and 1.8% other race/multi-race) are merged with tax data by residential state and interview month. Dependent variables include consumption of any alcohol and number of drinks consumed per month. Demand responses to alcohol taxes are estimated for each race/ethnicity in separate regressions conditional on individual characteristics, state and time fixed effects, and state-specific secular trends. RESULTS: The null hypothesis on the identical tax effects among all races/ethnicities is strongly rejected (P < 0.0001), although pairwise comparisons using t-test are often not statistically significant due to a lack of precision. Our point estimates suggest that the tax effect on any alcohol consumption is largest among White and smallest among Hispanic. Among existing drinkers, Native American and other race/multi-race are most responsive to tax effects while Hispanic least. For all races/ethnicities, the estimated tax effects on consumption are large and significant among light drinkers (1-40 drinks per month), but shrink substantially for moderate (41-99) and heavy drinkers (≥ 100). DISCUSSION: Extensive research has been conducted on overall demand responses to alcohol excise taxes, but not on heterogeneity across various racial/ethnic groups. Only one similar prior study exists, but used a much smaller dataset. The authors did not identify differential effects. With this much larger dataset, we found some evidence for different responses across races/ethnicities to alcohol taxes, although we lack precision for individual group estimates. Limitations of our study include the absence of intrastate tax variations, no information on what type of alcohol is consumed, lack of controls for subgroup baseline alcohol consumption rates, and measurement error in self-reported alcohol use data. IMPLICATIONS FOR HEALTH POLICIES: Tax policies aimed to reduce alcohol-related health and social problems should consider whether they target the most harmful drinking behaviors, affect subgroups in unintended ways, or influence some groups disproportionately. This requires information on heterogeneity across subpopulations. Our results are a first step in this direction and suggest that there exists a differential impact across races/ethnicities, which may further increase health disparities. Tax increases also appear to be less effective among the heaviest consumers who are associated with highest risk. IMPLICATIONS FOR FURTHER RESEARCH: More research, including replications in different settings, is required to obtain better estimates on differential responses to alcohol tax across races/ethnicities. Population heterogeneity is also more complex than our first cut by race/ethnicity and needs more fine-grained analyses and model structures.

The role of school physical activity programs in child body mass trajectory.

BACKGROUND: Physical activity at school can support obesity prevention among youth. This paper assesses the role of existing school physical activity programs for a national cohort from first grade to fifth grade. METHODS: We analyzed a cohort from the Early Childhood Longitudinal Survey-Kindergarten Cohort which included 8246 children in 970 schools across the country. Growth curve models estimate the effect of physical education (PE) and recess on individual child body mass trajectories controlling for child and school characteristics. Hierarchical models allow for unobserved school and child effects. RESULTS: Among first graders, 7.0% met the National Association of Sport and Physical Education (NASPE) recommended time for PE and 70.7% met the recommended time for recess in the previous week. Boys experienced a greater increase in body mass than girls. Meeting the NASPE recommended time for recess was associated with a 0.74 unit decrease in BMI (body mass index) percentile for children overall. Meeting the NASPE recommendation for physical education was associated with 1.56 unit decrease in BMI percentile among boys but not girls. CONCLUSIONS: We find evidence that meeting the national recommendations for PE and recess is effective in mitigating body mass increase among children.

Economic analysis of physical activity interventions.

BACKGROUND: Numerous interventions have been shown to increase physical activity but have not been ranked by effectiveness or cost. PURPOSE: This study provides a systematic review of physical activity interventions and calculates their cost-effectiveness ratios. METHODS: A systematic literature review was conducted (5579 articles) and 91 effective interventions promoting physical activity were identified, with enough information to translate effects into MET-hours gained. Cost-effectiveness ratios were then calculated as cost per MET-hour gained per day per individual reached. Physical activity benefits were compared to U.S. guideline-recommended levels (1.5 MET-hours per day for adults and 3.0 MET-hours per day for children, equivalent to walking 30 and 60 minutes, respectively). RESULTS: The most cost-effective strategies were for point-of-decision prompts (e.g., signs to prompt stair use), with a median cost of $0.07/MET-hour/day/person; these strategies had tiny effects, adding only 0.2% of minimum recommended physical activity levels. School-based physical activity interventions targeting children and adolescents ranked well with a median of $0.42/MET-hour/day/person, generating an average of 16% of recommended physical activity. Although there were few interventions in the categories of "creation or enhanced access to places for physical activity" and "community campaigns," several were cost effective. The least cost-effective categories were the high-intensity "individually adapted behavior change" and "social support" programs, with median cost-effectiveness ratios of $0.84 and $1.16 per MET-hour/day/person. However, they also had the largest effect sizes, adding 35%-43% of recommended physical activity, respectively. Study quality was variable, with many relying on self-reported outcomes. CONCLUSIONS: The cost effectiveness, effect size, and study quality should all be considered when choosing physical activity interventions.

Soda taxes, soft drink consumption, and children's body mass index.

Taxes on sugar-sweetened beverages have been proposed to combat obesity. Using data on state sales taxes for soda and individual-level data on children, we examine whether small taxes are likely to change consumption and weight gain or whether larger tax increases would be needed. We find that existing taxes on soda, which are typically not much higher than 4 percent in grocery stores, do not substantially affect overall levels of soda consumption or obesity rates. We do find, however, that subgroups of at-risk children--children who are already overweight, come from low-income families, or are African American--may be more sensitive than others to soda taxes, especially when soda is available at school. A greater impact of these small taxes could come from the dedication of the revenues they generate to other obesity prevention efforts rather than through their direct effect on consumption.

Potential societal savings from reduced sodium consumption in the U.S. adult population.

PURPOSE: Policies that address the food environment at the population level may help prevent chronic disease, but their value to society is still uncertain. Dietary sodium is linked to increased prevalence of hypertension, a primary risk factor for cardiovascular and renal diseases. This study calculates the potential societal savings of reducing hypertension and related cardiovascular disease via a reduction in population-level sodium intake. On average, U.S. adults consume almost twice the recommended maximum of dietary sodium, most of it from processed foods. DESIGN: This study modeled sodium-reduction scenarios by using a cross-sectional simulation approach. The model used population-level data on blood pressure, antihypertensive medication use, and sodium intake from the National Health and Nutrition Examination Survey (1999-2004). This data was then combined with parameters from the literature on sodium effects, disease outcomes, costs, and quality of life to yield model outcomes. MEASURES: This study calculated the following outcome measures: hypertension prevalence, direct health care costs, and quality-adjusted life years for noninstitutionalized U.S. adults. ANALYSIS: The simulation was conducted with STATA 9.2 and Microsoft Excel. Survey weights were used to calculate population averages. RESULTS: Reducing average population sodium intake to 2300 mg per day, the recommended maximum for adults, may reduce cases of hypertension by 11 million, save $18 billion health care dollars, and gain 312,000 QALYs that are worth $32 billion annually. Greater reductions in population sodium consumption bring even greater savings to society. CONCLUSIONS: Large benefits to society may result from efforts to lower sodium consumption on a population level by modest amounts over time. Although savings in direct health care costs are likely to be quite high, they could easily be matched or exceeded by the value of quality-of-life improvements.

Developing policy solutions for a more active nation: Integrating economic and public health perspectives.

Both economic and public health/medical perspectives play an important role in the policy process but often approach policy questions in an incompatible way. Harnessing any synergy requires an understanding of the other perspective. We begin by comparing and contrasting the economic and public health perspectives, including introducing relevant economic concepts. We next identify economic considerations for the development of environmental incentives that promote physical activity. We then assess features of the political environment which could impact the success of policy alternatives aimed at increasing physical activity. We conclude with several policy levers that may promote active living. Throughout the manuscript, we use the term economics to refer to classical economics and utility maximization rather than behavioral economics. In addition, we focus mostly on normative economics (which offers prescriptions for what should be done) rather than positive economics (which offers predictions of economic outcomes conditional on various hypothetical scenarios).

Alcohol environments and disparities in exposure associated with adolescent drinking in California.

OBJECTIVES: We investigated sociodemographic disparities in alcohol environments and their relationship with adolescent drinking. METHODS: We geocoded and mapped alcohol license data with ArcMap to construct circular buffers centered at 14 595 households with children that participated in the California Health Interview Survey. We calculated commercial sources of alcohol in each buffer. Multivariate logistic regression differentiated the effects of alcohol sales on adolescents' drinking from their individual, family, and neighborhood characteristics. RESULTS: Alcohol availability, measured by mean and median number of licenses, was significantly higher around residences of minority and lower-income families. Binge drinking and driving after drinking among adolescents aged 12 to 17 years were significantly associated with the presence of alcohol retailers within 0.5 miles of home. Simulation of changes in the alcohol environment showed that if alcohol sales were reduced from the mean number of alcohol outlets around the lowest-income quartile of households to that of the highest quartile, prevalence of binge drinking would fall from 6.4% to 5.6% and driving after drinking from 7.9% to 5.9%. CONCLUSIONS: Alcohol outlets are concentrated in disadvantaged neighborhoods and can contribute to adolescent drinking. To reduce underage drinking, environmental interventions need to curb opportunities for youth to obtain alcohol from commercial sources by tightening licensure, enforcing minimum-age drinking laws, or other measures.