The return on investment for the prevention and treatment of childhood and adolescent overweight and obesity in China: a modelling study.

Background: The rapid increase in child and adolescent overweight and obesity (OAO) in China has a significant health and economic impact. This study undertook an investment case analysis to evaluate the health and economic impacts of child and adolescent OAO in China and the potential health and economic returns from implementing specific policies and interventions. Methods: The analysis estimates the reduction in mortality and morbidity from implementing a set of evidence-based interventions across China between 2025 and 2092 using a deterministic Markov cohort model. Modelled interventions were identified by literature review and expert recommendation and include fiscal and regulatory policies, eHealth breastfeeding promotion, school-based interventions, and nutritional counselling by physicians. The study applies a societal costing perspective to model the economic impact on healthcare cost savings, wages, and productivity during adulthood. By projecting and comparing the costs between a status quo scenario and an intervention scenario, the study estimates the return on investment (ROI) for interventions separately and in combination. Findings: Without intervention China will experience 3.3 billion disability-adjusted life years (DALYs) due its current levels of child and adolescent OAO and a lifetime economic impact of CNY 218 trillion (USD 31.6 trillion), or a lifetime CNY 2.5 million loss per affected child or adolescent (USD 350 thousand). National implementation of all five interventions would avert 179.4 million DALYs and result in CNY 13.1 trillion of benefits over the model cohort's lifetime. Implementing fiscal and regulatory policies had the strongest ROI, with benefits accruing at least 10 years after implementation. Scaling up China's current school-based interventions offers China significant health and economic gains, however, the ROI is lower than other modelled interventions. Interpretation: Effective prevention and treatment of child and adolescent OAO is critical to China's health and economic development. Multiple interventions offer a comprehensive approach to address the various factors that increase risk of child and adolescent OAO. Nonetheless, fiscal and regulatory policies offer the strongest health and economic gains. Funding: Funding was provided by UNICEF China.

An investment case analysis for the prevention and treatment of adolescent mental disorders and suicide in England.

BACKGROUND: Adolescent mental health (AMH) needs in England have increased dramatically and needs exceed treatment availability. This study undertook a comparative assessment of the health and economic return on investment (ROI) of interventions to prevent and treat mental disorders among adolescents (10-19 years) and examined intervention affordability and readiness. METHODS: Interventions were identified following a review of published and grey literature. A Markov model followed a simulated adolescent cohort to estimate implementation costs and health, education, and economic benefits. Intervention affordability was assessed, comparing annual cost per adolescent with NHS England per capita spending, and an expert panel assessed intervention readiness using a validated framework. RESULTS: Over 10- and 80-year horizons, interventions to treat mild anxiety and mild depression were most cost-effective, with the highest individual lifetime ROI (GBP 5822 GBP 1 and GBP 257: GBP 1). Preventing anxiety and depression was most affordable and 'implementation ready' and offered the highest health and economic benefits. A priority package (anxiety and depression prevention; mild anxiety and mild depression treatment) would avert 5 million disability-adjusted life-years (DALYS) and achieve an ROI of GBP 15: GBP 1 over 10 years or 11.5 million DALYs (ROI of GBP 55: GBP 1) over 80 years. CONCLUSION: The economic benefits from preventing and treating common adolescent mental disorders equivalent to 25% of NHS England's annual spending in 2021 over 10 years and 91% over 80 years. Preventing and early treatment for anxiety and depression had the highest ROIs and strong implementation readiness.

Investment case for the prevention and reduction of childhood and adolescent overweight and obesity in Mexico.

Despite efforts to curb the rise in Mexico's child and adolescent overweight and obesity rates, prevalence in Mexico has grown by 120% since 1990 to 43.3% in 2022. This investment case identifies policies that will produce the largest returns for Mexico. The investment case model builds beyond a cost-of-illness analysis by predicting the health and societal economic impact of implementing child and adolescent overweight and obesity interventions in a cohort aged 0-19 from 2025 to 2090. The Markov model's impacts include healthcare expenditures, years of life lost, and reduced wages and productivity. We projected and compared costs in a status quo scenario to an intervention scenario to estimate cost savings and calculate return-on-investment (ROI). Total lifetime health and economic costs amount to USD 1.8 trillion-USD 30 billion on average per year. Implementing five interventions can reduce lifetime costs by approximately 7%. Each intervention has a low cost per disability-adjusted life year averted over 30-year, 50-year, and lifetime horizons. The findings demonstrate that a package of interventions mitigating child and adolescent overweight and obesity offers a strong ROI. The novel investment case methods should be applied to other countries, particularly low- and middle-income countries.

The case for investing in the prevention and treatment of overweight and obesity among children and adolescents in three middle-income countries.

BACKGROUND: Child and adolescent overweight and obesity rates are increasing rapidly, notably in middle-income countries (MICs). Effective policy adoption has been limited in low-income and middle-income countries. To respond, investment cases were developed in Mexico, Peru, and China to understand the health and economic returns on investment in childhood and adolescent overweight and obesity interventions. METHODS: The investment case model applied a societal perspective to predict the health and economic impact of childhood and adolescent overweight and obesity in a cohort aged 0-19 years, beginning in 2025. Impacts include health-care expenditures, years of life lost, reduced wages, and productivity. Unit cost data from the literature was used to develop a status quo scenario over the model cohort's average expected lifetime period (2025-90 in Mexico; 2025-92 in China and Peru) and was compared with an intervention scenario to estimate cost savings and calculate return on investment (ROI). Effective interventions were identified from the literature and selected to reflect country-specific prioritization after stakeholder discussions. Priority interventions range from fiscal policies, social marketing, breastfeeding promotion, school-based policies, and nutritional counselling. FINDINGS: Total predicted lifetime health and economic impacts of child and adolescent overweight and obesity in the three countries ranged from US$1·8 trillion in Mexico, $211 billion in Peru, and $33 trillion in China. Implementing a set of priority interventions in each country could reduce lifetime costs by $124 billion (Mexico), $14 billion (Peru), and $2 trillion (China). Implementing a unique package of interventions for each country resulted in a predicted lifetime ROI of $515 per $1 invested in Mexico, $164 per $1 in Peru, and $75 per $1 in China. Fiscal policies were very cost-effective and had positive ROIs in all three countries for 30-year, 50-year, and lifetime time horizons until 2090 (Mexico) or 2092 (China and Peru). Although school interventions had a positive ROI in all countries across a lifetime horizon, relatively they yielded considerably lower ROIs than other interventions evaluated. INTERPRETATION: Lifetime health and economic impacts of child and adolescent overweight and obesity across the three MICs are high and will undermine countries' ability to meet sustainable development goals. Investing in nationally relevant cost-effective interventions could reduce lifetime costs. FUNDING: UNICEF, partly supported by a grant from Novo Nordisk.

Identifying the necessary capacities for the adaptation of a diabetes phenotyping algorithm in countries of differing economic development status.

BACKGROUND: In 2019, the World Health Organization recognised diabetes as a clinically and pathophysiologically heterogeneous set of related diseases. Little is currently known about the diabetes phenotypes in the population of low- and middle-income countries (LMICs), yet identifying their different risks and aetiology has great potential to guide the development of more effective, tailored prevention and treatment. OBJECTIVES: This study reviewed the scope of diabetes datasets, health information ecosystems, and human resource capacity in four countries to assess whether a diabetes phenotyping algorithm (developed under a companion study) could be successfully applied. METHODS: The capacity assessment was undertaken with four countries: Trinidad, Malaysia, Kenya, and Rwanda. Diabetes programme staff completed a checklist of available diabetes data variables and then participated in semi-structured interviews about Health Information System (HIS) ecosystem conditions, diabetes programme context, and human resource needs. Descriptive analysis was undertaken. RESULTS: Only Malaysia collected the full set of the required diabetes data for the diabetes algorithm, although all countries did collect the required diabetes complication data. An HIS ecosystem existed in all settings, with variations in data hosting and sharing. All countries had access to HIS or ICT support, and epidemiologists or biostatisticians to support dataset preparation and algorithm application. CONCLUSIONS: Malaysia was found to be most ready to apply the phenotyping algorithm. A fundamental impediment in the other settings was the absence of several core diabetes data variables. Additionally, if countries digitise diabetes data collection and centralise diabetes data hosting, this will simplify dataset preparation for algorithm application. These issues reflect common LMIC health systems' weaknesses in relation to diabetes care, and specifically highlight the importance of investment in improving diabetes data, which can guide population-tailored prevention and management approaches.

Weight stigma among adolescents in three low- and middle-income countries.

Background: Overweight (OW) and obesity affect millions of adolescents worldwide. Evidence from high-income countries indicates widespread weight stigma that adversely affects young people's mental and physical health. However, evidence relating to low- and middle-income countries (LMICs) is sparse. We aimed to generate insight into weight stigma prevalence and experience among adolescents in three LMICs. Methods: We identified adolescents aged 15-19 from Brazil, South Africa, and Indonesia from families within market research databases. We adopted a mixed-methods design. The sample included equal numbers by country, sex, and age, and included urban and rural dwellers. Self-reported weight was recorded but was not a selection criterion. Consent (age >18) and assent/parental consent (

The global return on investment from preventing and treating adolescent mental disorders and suicide: a modelling study.

INTRODUCTION: Despite the high burden of mental disorders among adolescents and the potentially lifelong consequences of these conditions, access to mental health services remains insufficient for adolescents in low-income and middle-income countries. We conducted an economic modelling study to quantify the potential costs and benefits of mental health interventions to prevent or treat anxiety, depression, bipolar disorder, and suicide among adolescents. METHODS: We developed a Markov model that followed cohorts of adolescents (ages 10-19) from 36 countries to assess the impact of addressing anxiety, depression, bipolar disorder, and suicide during adolescence on health and non-health outcomes through their lives. We estimated the costs of interventions using an ingredients-based approach and modelled impacts on education and employment and the resulting economic, morbidity, and mortality benefits. RESULTS: Implementing the selected interventions offers a return on investment of 23.6 and a cost of $102.9 per disability adjusted life year (DALY) averted over 80 years. The high return on investment and low cost per DALY averted is observed across regions and country income levels, with the highest return on investment arising from treating mild depression with group-based cognitive behavioural therapy, prevention of suicide attempts among high-risk adolescents, and universal prevention of combined anxiety and depression in low-income and lower-middle income countries. CONCLUSIONS: The high return on investment and low cost per DALY averted suggests the importance and value of addressing mental disorders among adolescents worldwide. Intervening to prevent and treat these mental disorders even only during adolescence can have lifelong health and economic benefits.

'Implementability' matters: using implementation research steps to guide and support non-communicable disease national planning in low-income and middle-income countries.

The 'implementation gap' between national plans and successful implementation is a central theme in addressing non-communicable diseases (NCDs). It is a factor that has undermined Sustainable Development Goal 3.4, which aims to achieve a one-third reduction in premature mortality from four major NCDs by 2030. Responding to the potential of implementation research to support low-income and middle-income countries to effectively advance their strategies, we describe ways to make NCD plans more robust by including implementation steps. These steps are (1) choosing some (but not all) effective and cost-effective options; (2) tailoring interventions and their scale-up to national capacity; and (3) making the priorities implementable. We illustrate with examples from several countries.

Indiana Sexual Assault Nurse Examiner Training Initiative: Positive Impacts for Medical Forensic Care.

BACKGROUND: Indiana ranks among the highest in the nation for child abuse and neglect reports. Already facing a persistent shortage of sexual assault nurse examiners (SANEs) to serve patients across the life span, residents with medical forensic needs were often being referred to other hospitals across the state for care or simply were not receiving medical forensic examinations because of lack of access to trained examiners. The Indiana SANE Training Project was established to evaluate the forensic nursing workforce throughout Indiana and work to expand access to qualified SANEs through training and collaboration with stakeholders, with a focus on rural and underserved areas of the state. METHODS: The Project gathered information from nurses who participated in activities during the first Project year. This information was evaluated for service gaps and ongoing training needs. The project coordinator then convened a workgroup of stakeholders and subject matter experts to evaluate and respond to the most immediate need-limited access to pediatric medical forensic providers. RESULTS: From September 2018 to December 2019, nurses were trained by the Project ( n = 160). Of those, 86% indicated that their hospital did not provide medical forensic examinations to pediatric patients. The Pediatric SANE Intensive was launched in October 2020 and trained pediatric SANEs ( n = 28). Upon completion, participants reported 47% increase in confidence and 56% increase in competence related to caring for pediatric patients. DISCUSSION: Statewide collaboration is a critical component of establishing a consistent approach to care, strengthening multidisciplinary partnerships, increasing access to medical forensic services across the life span and in rural and underserved areas, and promoting the Indiana Guidelines for Medical Forensic Examination of Pediatric Sexual Abuse Patients.

An Evaluation of Hepatitis C Screening in Infants and Children Born to Seropositive Mothers in Saint John, New Brunswick.

BACKGROUND: The primary route of hepatitis C virus (HCV) infection in children is vertical transmission, from mother to fetus in utero. There is a lack of data on the prevalence of pediatric HCV acquired through vertical transmission in Saint John, New Brunswick. Furthermore, what risk factors may be associated with an increased likelihood for a child born to an HCV-seropositive mother should be known to direct screening practices. METHODS: A retrospective chart review of the active charts from the local HCV clinic, the Centre for Research, Education & Clinical Care of At-Risk Populations (RECAP), identified HCV-seropositive women who had children at-risk of HCV through vertical transmission. Sociodemographic information and various risk factors were collected, including maternal HCV genotype, non-prescription drug use subcategorized into intravenous drug use and snorting, transfusion history, involvement in opiate substitution therapy, postal code as a proxy for socioeconomic status, and issues of custodianship within the family. A 2 x 2 chi-square analysis was conducted to assess the frequency of HCV screening for children by the presence or absence of familial custodianship issues. RESULTS: In total, data from 62 HCV-seropositive women and 123 infants and children at-risk for HCV were included in this study. HCV status at the time of pregnancy revealed 18 (14.6%) with a positive HCV screen, 14 (11.4%) with a positive viral load, and 91 (74.0%) with unknown status. A total of 30 children (24.4%) had HCV screening performed, of which three (10.0%) were HCV-antibody positive and had a detectable viral load. Results of the chi-square analysis indicated that issues of custodianship had no significant influence on child screening rates. CONCLUSION: Overall, this study highlighted the inconsistent screening practices of children at-risk for HCV through vertical transmission, as well as the need for improvement in chart documentation and follow-up. Clinicians and researchers should focus their efforts toward proactively identifying children at-risk for HCV through vertical transmission. This could involve screening during pregnancy and subsequent follow-up, or at other points of contact with the healthcare system, such as parental involvement with opioid substitution therapy or well-child visits. Implementation of a targeted screening program could be considered in urban centers similar to the one in this study to connect at-risk populations with essential medical and community services.

A Novel Lysolecithin Model for Visualizing Damage in vivo in the Larval Zebrafish Spinal Cord.

Background: Lysolecithin is commonly used to induce demyelinating lesions in the spinal cord and corpus callosum of mammalian models. Although these models and clinical patient samples are used to study neurodegenerative diseases, such as multiple sclerosis (MS), they do not allow for direct visualization of disease-related damage in vivo. To overcome this limitation, we created and characterized a focal lysolecithin injection model in zebrafish that allows us to investigate the temporal dynamics underlying lysolecithin-induced damage in vivo. Results: We injected lysolecithin into 4-6 days post-fertilization (dpf) zebrafish larval spinal cords and, coupled with in vivo, time-lapse imaging, observed hallmarks consistent with mammalian models of lysolecithin-induced demyelination, including myelinating glial cell loss, myelin perturbations, axonal sparing, and debris clearance. Conclusion: We have developed and characterized a lysolecithin injection model in zebrafish that allows us to investigate myelin damage in a living, vertebrate organism. This model may be a useful pre-clinical screening tool for investigating the safety and efficacy of novel therapeutic compounds that reduce damage and/or promote repair in neurodegenerative disorders, such as MS.

Tailored support for national NCD policy and programme implementation: an over-looked priority.

Many low-income and middle-income countries (LMICs) are unlikely to achieve Sustainable Development Goal 3.4 to reduce premature deaths from non-communicable diseases (NCDs) by one-third by 2030. For some, the prospect is receding: between 2010 and 2020, the decline in premature deaths for the major NCDs slowed compared with the prior decade. Barriers to implementing effective strategies are well known, yet the value of tailored technical support to countries has been overlooked and downplayed. Tailored technical support is specialist guidance for country-specific application of technical tools, and capacity enhancement when needed, that enables an LMIC to advance its NCD priorities and plans. We present a model identifying pivotal junctures where tailored technical support can help surmount implementation obstacles. We draw on our experience preparing NCD investment cases with health ministries, development partners and technical agencies. National investment cases produce evidence based, locally tailored and costed packages of NCD interventions and policies appropriate to national needs and circumstances. They can include analysis of financing needs and point towards sustainable funding mechanisms. Enhancing the NCD-specific knowledge of government and Civil Society Organization leads can capitalise on existing expertise, aid integrative health system developments and unlock capabilities to use global tools and guidance. Investment cases form a platform to develop or review NCD plans and (re)prioritise action, then apply implementation science to trouble-shoot obstacles. Partnering national stakeholders with technical support in this process is critical to develop and implement effective NCD strategies.

Key factors in achieving increased tobacco taxation: Experience from the island of Saint Helena.

Concerted efforts by government officials and technical assistance from the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) Secretariat Knowledge Hub on Tobacco Taxation and Illicit Trade, resulted in an increase in tobacco taxation in Saint Helena during 2019. This formed part of a broader package of Tobacco Control measures to reduce the burden of noncommunicable diseases (NCD) on the island. We elaborate on key contextual and contributing factors that resulted in positive policy change in a relatively short period of time. These included political support for a strategic approach to address prevalent NCD in the context of an ageing population, high overseas health care costs and Overseas Development Aid dependency. Previous experience of impact from sugar-sweetened beverage taxation when combined with wider system measures, and the similar accompaniment of the tobacco taxation proposals with wider measures, encouraged policymakers to use tobacco taxation to curb cigarette consumption. These factors created readiness, and tailored technical assistance from an international, donor-funded partner and specifically modelling to provide evidence-based predictions of impact augmented confidence of policy benefit and enabled passage. This experience may serve as a point of reference for other countries that wish to implement similar policy changes.

Strengthening resistance to the COVID-19 pandemic and fostering future resilience requires concerted action on obesity.

Initial observations showed that people with chronic noncommunicable diseases were at heightened risk of severe COVID-19 and adverse outcomes. Subsequently, data from various countries have revealed obesity as an independent and significant factor, with people who are overweight/have obesity significantly more likely to be hospitalized, require ICU treatment, and to die. Notably, this additional risk applies to younger people relative to the general COVID-19 risk profile. This paper sets out the evidence of greater risk of poor COVID outcomes for people who are overweight/have obesity, indication of reduced treatment and support for obesity self-management where it existed prior to COVID-19, and highlights the dearth of specific guidance and measures to mitigate the impacts of COVID-19 upon people with obesity. We identify the health, social and economic impacts that this specific vulnerability creates relative to COVID-19 outcomes. Reduced national and global pandemic resilience due to high obesity prevalence should spur governments and funders to provide urgent specific protection and support for people with overweight/obesity, and to commission rapid research to identify effective prevention and reduction measures. We set out priorities for action on obesity to begin compensating for years of underfunding and inadequate policy attention in the face of escalating obesity across countries of all income groups and world regions.

A 'whole systems' approach to reduce sugar-sweetened beverage consumption: issues for global health promotion through a small island lens.

Reducing sugar-sweetened beverage (SSB) consumption is a prominent strategy to reduce sugar intake and non-communicable disease (NCD) risk worldwide. Recommended measures encompass policy, environmental modification, health literacy, reformulation and taxation. This commentary draws from an intervention to reduce SSB consumption in a remote, rural context with high intake and under-developed alternatives and health literacy. The island of St Helena introduced SSB taxation from 2014, yet impact appeared limited. In 2018, supply and demand measures for substitute products were developed, alongside a taxation increase. Preliminary data indicate a shift away from SSB towards non-sugar beverages (artificially sweetened beverages (ASB) and tap water). Issues for global health promotion include the specific manifestation of social and commercial determinants of health in remote and rural contexts, integrated multifaceted strategies to provide supporting conditions for policies such as SSB taxation to deliver impact, and the role of ASB to reduce SSB in high consumption contexts.

The contribution of a 'whole of government' smoke-free policy on the island of St Helena.

Under its Health Promotion Strategic Framework 2018-19 the St Helena Government prioritised action to address smoking and obesity to reduce a high non-communicable disease burden. The first tobacco control measure was a policy, 'Smoke-Free Government' (SFG), to create smoke-free public outdoor and indoor sites across all sites and services for staff and public users, abolish 'official' staff 'smoking breaks', and establish and promote community-wide cessation support. This paper assesses the perceived acceptability and preliminary impact of SFG in St Helena 2018-19. An online survey of government staff was undertaken 6 months post-SFG implementation to obtain insight into perceived impact, implementation, and acceptability. A population-wide health survey provided smoking prevalence and quit data prior to, and 11 months post-implementation. A majority of staff believed the policy contributed to reducing smoking, was generally observed, accepted, and entailed one or more positive effects, including reduced second-hand smoke exposure, increased quit attempts, and reduced disruption from 'smoke-breaks'. Recommendations were consistent enforcement and expanded quit support. Population data for the SFG period indicated that smoking, and particularly daily smoking declined, quit intentions increased, and quit attempts almost doubled. The SFG policy appears to have contributed positively towards stronger tobacco control in St Helena in 2018-19.

Transmission electron microscopy of zebrafish spinal motor nerve roots.

BACKGROUND: Spinal motor nerves are essential for relaying information between the central and peripheral nervous systems. Perturbations to cell types that comprise these nerves may impair rapid and efficient transmission of action potentials and alter nerve function. Identifying ultrastructural changes resulting from defects to these cellular components via transmission electron microscopy (TEM) can provide valuable insight into nerve function and disease. However, efficiently locating spinal motor nerves in adult zebrafish for TEM is challenging and time-consuming. Because of this, we developed a protocol that allows us to quickly and precisely locate spinal motor nerve roots in adult zebrafish for TEM processing. RESULTS: Following fixation, a transverse slab of adult zebrafish dissected from the trunk region was mounted in embedding media, sectioned, and secondary fixation with osmium tetroxide performed. Transverse sections containing motor nerves were selected for TEM ultrathin sectioning and imaging. CONCLUSIONS: We developed an efficient protocol for locating spinal motor nerves in adult zebrafish to allow for ultrastructural characterization. Although our work focuses on spinal motor nerves, this protocol may be useful for efficiently identifying other discrete, repeated structures within the developing and mature nervous system that are difficult to find via traditional, whole organism TEM processing. Developmental Dynamics 246:956-962, 2017. © 2017 Wiley Periodicals, Inc.