Benefits of Nutrition education and intervention

[Kuester, Sarah]

Dear colleagues:
Thanks to all of you who responded to my request for potential
resources that may demonstrate cost effectiveness of nutrition
interventions.  The following items are from  MedLINE  and
Combined Health Information Database (CHID) literature searches
and responses to my listserv inquiries.
If you have any other resources, please let me know.

Happy holidays!
Sarah Kuester
Centers for Disease Control & Prevention
sak2 at cdc.gov
 -------------------------------------------------------------
1. The November 1991 supplement of the Journal of the American
Dietetics Association includes articles on cost effectiveness.
A good contact is one of the authors, Pat Splett at the University of
Minnesota, who specializes in these analyses.  She has written a book
called "The Practitioner's Guide to Cost-Effectiveness Analysis of
Nutrition Interventions" published by the Maternal and Child Health
Bureau for $10.00.

2. Visit the web site: <http://www.ext.vt.edu/efnepcba>. This is
Virginia
Extension's work on cost benefit analysis for EFNEP.

3.  Barbara Nolan, MS, RD, the program coordinator of the Have
a Healthy Baby program out of Purdue University can share copies
of their fact sheet which describes the impact of nutrition education
on birth outcome (decrease in low birth weights) and change in maternal
eating habits over the course of their six lessons.  She can be reached
at bnolan at purdue.edu

4.  Four state health departments and CDC conducted a work-site
cholesterol screening and education program in the early 90's.
The results article includes a cost-benefit analysis in
AJPH 1995; 85:650, 655 by Tim Byers et al entitled "The Costs
and Effects of a Nutritional Educational Program Following
Work-Site Cholesterol Screening."

5.  Although a cost piece is not included, a recent article in
AJPH was recommended that ties nutrition education to CVD risk.
See Brunner et al. "Can dietary interventions change diet &
cardiovascular risk factors? A meta-analysis of  randomized
controlled trials." AJPH 1997; 87-1415-22.

6.  Agneta Yngve from the Karolinska Institutet in Sweden (E-mail:
agneta.yngve at cnt.ki.se and WWW: http://www.prevnut.ki.se/info/)
shared that recently the Health Education Authority in the UK
published a book called Health promotion interventions to
promote healthy eating in the general population: a review. This is
one in a series of books called Health promotion effectiveness reviews.
You can reach HEA through their website http://www.hea.uk

7. From a food assistance perspective, economic analysis
is available on the WIC Program.

8.  The  following are abstracts I pulled from a lit. search on
costs and cost analysis of nutrition education and interventions.

Tosteson AN.  Weinstein MC.  Hunink MG.  Mittleman MA.  Williams LW.
Goldman PA.  Goldman L.
"Cost-effectiveness of populationwide educational approaches to reduce
serum cholesterol levels."  Circulation.  95(1):24-30, 1997 Jan 7.
Abstract
  BACKGROUND: The aim of the present study was to estimate the
  cost-effectiveness of populationwide approaches to reduce serum
  cholesterol levels in the US adult population. METHODS AND RESULTS:
This
  cost-effectiveness analysis was made from data from the literature and
the
  Coronary Heart Disease Policy Model and was based on the US population
age
  35 to 84 years. Study interventions were populationwide programs to
reduce
  serum cholesterol levels with costs and cholesterol-lowering effects
  similar to those reported from the Stanford Three-Community Study, the
  Stanford Five-City Project, and in North Karelia, Finland. The main
  outcome measures were cost-effectiveness ratios, defined as the change
in
  projected cost divided by the change in projected life-years when the
  population receives the intervention compared with the population
without
  the intervention. A populationwide program with the costs ($4.95 per
  person per year) and cholesterol-lowering effects (an average 2%
reduction
  in serum cholesterol levels) of the Stanford Five-City Project would
  prolong life at an estimated cost of only $3200 per year of life
saved.
  Under a wide variety of assumptions, a populationwide program would
  achieve health benefits at a cost equivalent to that of many currently
  accepted medical interventions. Such programs would also lengthen life
and
  save resources under many scenarios, especially if the program
affected
  persons with preexisting heart disease or altered other coronary risk
  factors. CONCLUSIONS: Populationwide programs should be part of any
  national health strategy to reduce coronary heart disease.

Johannesson M.  Agewall S.  Hartford M.  Hedner T.  Fagerberg B.
"The cost-effectiveness of a cardiovascular multiple-risk-factor
  intervention programme in treated hypertensive men."
  Journal of Internal Medicine.  237(1):19-26, 1995 Jan.
Abstract
  OBJECTIVES. The aim of this study was to carry out a
cost-effectiveness
  analysis of a multifactorial intervention programme in treated
  hypertensive patients. DESIGN. A cost-effectiveness analysis based on
3
  years of follow-up in an open, randomized, parallel-group study with
  allocation either to a comprehensive, multiple-risk factor
modification
  programme or to conventional treatment. SETTING. An outpatient clinic
of a
  city hospital. SUBJECTS. Inclusion criteria were: male sex, age 50-72
  (mean 66.4) years, treated hypertension and at least one of the
following:
  serum cholesterol > or = 6.5 mmol L-1, and/or smoking and/or diabetes
  mellitus. A total of 508 patients were included in the study.
  INTERVENTIONS. Advice given to individuals, and group meetings based
on
  nutritional advice and behavioural treatment principles. If necessary,
  drug therapy could be instituted to achieve the treatment goals in the
  intervention group: serum total cholesterol of < 6.0 mmol L-1, no
smoking,
  HbAlc < 6.0% and diastolic blood pressure < 90 mmHg in both groups.
MAIN
  OUTCOME MEASURE. Incremental cost per life-year gained of the
intervention
  programme. RESULTS. The cost per life-year gained was SEK 4000 in an
  estimation based on the observed risk reduction and ranged between SEK
  62,000 and SEK 163,000 in three estimations based on the risk factor
  changes. CONCLUSIONS. The analysis indicates that the intervention
  programme is cost-effective in the studied patient population.

Oldenburg B.  Owen N.  Parle M.  Gomel M.
"An economic evaluation of four work site based cardiovascular risk
factor
  interventions."  Health Education Quarterly.  22(1):9-19, 1995 Feb.
Abstract
  We used outcome data from a randomized work site intervention trial to
  examine the cost-effectiveness of four cardiovascular disease (CVD)
risk
  reduction programs: health risk assessment (HRA), risk factor
education
  (RFE), behavioral counseling (BC), and behavioral counseling plus
  incentives (BCI). Composite CVD risk scores were derived from measures
of
  serum total cholesterol, blood pressure, number of cigarettes smoked,
body
  mass index, and aerobic capacity. The economic evaluation of the
programs
  focused on the subset of costs most sensitive to the differences
between
  the interventions, and a sensitivity analysis examined some of the
  relevant cost variations. At the 6-month follow-up (i.e., the "action"
or
  initiation stage of lifestyle change), the RFE, BC, and BCI
interventions
  produced a significant reduction in cardiovascular risk. Incremental
  analyses demonstrated RFE to be more cost-effective, but not as
clinically
  effective as BC; BC was more cost-effective than RFE when assessment
costs
  were included, and BCI was judged to be the least cost-effective. At
the
  12-month follow-up (i.e., the "maintenance" stage of lifestyle of
change),
  BC was the only program found to produce a significant reduction in
CVD
  risk. Individualized behavioral counseling was found to be a
  cost-effective strategy for the initiation and maintenance of CVD risk
  factor reduction.

Lovato, C.Y.; Green, L.W.; Stainbrook, G.L.
"Benefits Anticipated by Industry in Supporting Health Promotion
Programs in
   the Worksite" in  Economic Impact of Worksite Health Promotion.
Opatz, J.P.; ed.
   Champaign, IL, Human Kinetics Publishers, pp. 3-31, 1994.
Abstract
   Benefits Anticipated by Industry in Supporting Health Promotion
Programs in
   the Worksite, a book chapter in Economic Impact of Worksite Health
   Promotion, examines the growth of the worksite health promotion
movement, 
   assesses the rationale and experience behind three programs adopted
by the
   industry, and attempts to account for the diffusion of programs among
   employers. Epidemiological importance and the demonstrated
effectiveness of
   interventions were criteria used by the Public Health Service to
establish
   national priorities in health promotion. Common criteria used in
setting
   health promotion priorities for worksite health promotion included
(1)
   cost-benefit and cost-effectiveness considerations, (2) prior
demonstration
   of benefits in comparable sites, (3) time frame for the realization
of
   benefits, (4) relevance of the program to health costs and risks in
the
   company, (5) employee interest in the program, and (6) possible
negative
   effects of the program. The work setting represents the single most
   important channel to systematically reach the adult population
through
   health information and health promotion programs. A 1986 survey
sponsored 
   by the U.S. Department of Health and Human Services found that the
most
   frequently cited categories of worksite health promotion activities
   included (1) smoking control, (2) health risk assessment, (3) back
problem
   prevention and care, (4) stress management, (5) exercise and fitness,
(6) 
   off-the-job accident prevention, (7) nutritional education, (8) blood
   pressure control, and (9) weight control. The worksite health
programs most
   commonly supported by employers were (1) smoking control, including
   nonsmoking policies and smoking cessation programs; (2) alcohol abuse
   detection and treatment, including employee assistance programs; and
(3)
   increased physical activity, including fitness programs. Researchers
found
   that worksite health programs were increasing because they (1) were
popular
   with employees; (2) supplied management with positive, constructive,
   relatively low-cost benefits for employees; (3) improved both health
and
   productivity indicators in the short term; and (4) reduced medical
care
   expenditures in the long term.

Whitmer, R.W.; Hilyer, J.C.; Brown, K.C.
"Medical Benefits Cost Containment: The Municipal Government of
Birmingham,
   Alabama" in Economic Impact of Worksite Health Promotion. Opatz,
J.P.; ed.
   Champaign, IL, Human Kinetics Publishers, pp. 177-191, 1994.
Abstract
   Medical Benefits Cost Containment: The Municipal Government of
Birmingham,
   Alabama, a book chapter in Economic Impact of Worksite Health
Promotion,
   discusses the findings of an experimental cost-containment project.
Based 
   on results of a 1-year pilot program, the basic project design for
the 5-
   year program included an annual medical screening, aggressive
physician
   referral, and health education and intervention programs addressing
(1)
   nutrition, (2) weight loss, (3) smoking cessation, (4) blood pressure
   control, (5) cholesterol reduction, and (6) preventing back injuries.
   Because the medical screen was made a prerequisite for medical
benefits,
   approximately 95 percent of full-time employees participated annually
in
   the medical screen from 1985 through 1990. After the medical screen,
   researchers randomly assigned participants to one of four equal-sized
   groups: (1) Group A employee and their spouses had access to all
segments 
   of the program at no cost; (2) group B also had free and total
access,
   except that spouses could not participate; (3) group C was permitted
to
   participate in weight-control and exercise interventions only and
spouses 
   could participate; and (4) group D served as the control group.
Comparisons
   among the groups included (1) the cost of medical care, (2) number of
   hospital admissions, (3) number of physician visits, (4) number of
and kind
   of major disease diagnoses, (5) measurable lifestyle changes, (6)
number
   and type of medical problems that occur in those perceived to be less
   healthy, (7) the effect of dependent participation, (8) effectiveness
of
   regular and supervised exercise, (9) absenteeism due to illness, (10)
job 
   turnover, and (11) feelings of well-being and job satisfaction.
Results
   showed that (1) over the 5-year period, the city held its employer
medical
   costs constant while medical benefit costs for the average employer
in the
   United States doubled; (2) 13 percent of the employees had medical
findings
   serious enough to require referral to a physician; (3) approximately
43
   percent of the employees did not have a regular doctor, and only 17
percent
   wanted help in finding a regular doctor; (4) the average time since
the
   last doctor visit was 35 months; and (5) for the 5-year period,
actual
   medical benefits expenses were 21.1 percent below the national, per-
   employee average.

Fielding, J.E.
"LIVE FOR LIFE Program of Johnson and Johnson: Direct and Indirect
Economic
   Benefits" in  Economic Impact of Worksite Health Promotion. Opatz,
J.P.; ed.
   Champaign, IL, Human Kinetics Publishers, pp. 209-228, 1994.
Abstract
   LIVE FOR LIFE Program of Johnson and Johnson: Direct and Indirect
Economic
   Benefits, a book chapter in Economic Impact of Worksite Health
Promotion, 
   discusses direct and indirect benefits of the Live for Life worksite
health
   promotion program at Johnson and Johnson. The Live for Life system of
   programs encompassed (1) a wellness program, (2) an occupational
health
   program, (3) the medical portion of the employee benefit plan, (4)
the
   employee assistance program, and (5) the safety program. All
employees are
   encouraged to take a nurse-administered health profile that includes
   behavioral; attitudinal; and biometric measures (e.g., blood
pressure,
   blood lipids, body fat, height and weight, and submaximal exercise
testing)
   . Employees participate in a 3-hour lifestyle seminar. The core of
   lifestyle improvement activities included behaviorally oriented
programs
   dealing with (1) nutrition, (2) exercise, (3) weight control, (4)
smoking 
   cessation, (5) stress management, and (6) blood pressure control. To
   evaluate the program's intervention impact, researchers maintained
the
   quasi-experimental design of the study for 2 years among two sets of
   Johnson and Johnson manufacturing plants that were located within a
50-mile
   radius of each other and had comparable demographics and job-class
   distributions. Some plants introduced the entire Live for Life
program to 
   2,600 employees, while three companies offered only the health
screening
   component to 1,700 employees. Preliminary findings after the first 12
   months indicated that, compared to the control group, the Life for
Life
   group showed improvement in (1) weight control, (2) exercise, (3)
blood
   pressure control, (4) percent body weight above ideal body weight,
(5)
   cigarette smoking cessation, and (6) self-reported sick days.
Inpatient
   costs for the Live for Life groups grew at a significantly lower rate
than
   did those for the control group, on average $43 and $42 a year for
the
   study groups compared with $76 for the control group. Intervention
group
   costs in constant dollars approximately doubled during the 5-year
study
   period, compared with the 4-fold increase that occurred in costs for
the
   control group; this equaled $245,079 a year for the Live for Life
groups.

Johannesson, M.; Agewall, S.; Hartford, M.; Hedner, T.; Fagerberg, B.
"Cost-effectiveness of a Cardiovascular Multiple-risk-factor
Intervention
   Programme in Treated Hypertensive Men"
Journal of Internal Medicine. 237(1):19-26, January 1995.
Abstract
   Researchers in Sweden conducted a cost-effectiveness analysis of a
   multifactorial intervention program in treated hypertensive males.
   Researchers calculated the cost-effectiveness ratio as the net costs
(the 
   treatment costs minus saved costs of reduced cardiovascular
morbidity) of 
   the multifactorial treatment program divided by the increased number
of
   life-years gained compared with the conventional drug treatment.
   Researchers used a treatment duration of 3 years to estimate the
cost-
   effectiveness ratio based on the 3-year followup in the trial. They
   calculated costs in 1991 prices in Swedish crowns (SEK). The sample
   included 508 patients, aged 50-72, at an outpatient clinic of a city
   hospital. Subjects had treated hypertension and serum cholesterol
greater 
   than or equal to 6.5 mmol L, and/or smoking, and/or diabetes
mellitus. The
   intervention included individual advice and group meetings based on
   nutritional advice and behavioral treatment principles, and use of
drug
   therapy as necessary. Researchers conducted estimations based on
changes in
   the risk factors. After 3 years' followup, the change in total
cholesterol
   and smoking had statistical significance at the 5 percent level. The
change
   in diastolic blood pressure was statistically significant after 1
year's
   but not after 3 years' followup. The extra costs for the 3 years of
the
   intervention program came to about SEK 5,000 per patient. The cost
per
   life-year gained came to SEK 4,000 based on the observed risk
reduction,
   and ranged between SEK 62,000 and SEK 163,000 in three estimations
based on
   the risk factor changes. Findings indicated the cost-effectiveness of
the 
   intervention in the studied population. 5 tables, 33 references.

Report by Anthem Health Systems:
"Staying Alive and Well at Reynolds Electrical and Engineering Company,
Inc."
Indianapolis, IN, Anthem Health Systems, 45 p., 1993.
(Anthem Health Systems, 5451 West Lakeview Parkway South Drive,
   Indianapolis, IN 46268)
Abstract
   Staying Alive and Well at Reynolds Electrical and Engineering
presents a
   case study of the results of the Stay Alive and Well program
conducted at 
   Reynolds Electrical and Engineering Company in Las Vegas, Nevada,
between 
   1988-1989. It compares the results to those of the Health Promotion
Service
   Evaluation and Impact Study conducted at Blue Cross and Blue Shield
of
   Indiana from 1977 to 1982. The Health Promotion Service program, the
   original Stay Alive and Well program, focused on nutrition, weight
   reduction, and smoking cessation. Reynolds Electrical and
Engineering's
   program added other topics, including back care, breast health,
stress
   management, skin cancer, heart health, cardiopulmonary resuscitation
(CPR),
   and acquired immunodeficiency syndrome (AIDS) in the workplace. To
evaluate
   the program, Reynolds Electrical staff collected data at 6-month
intervals
   on program participation rates, outcome measures, health risk
indicators, 
   insurance utilization data, and program costs. Program participation
rates
   were approximately 51 percent, and intervention program completion
rates
   ranged from 56 percent to 80 percent. These rates equalled or
exceeded
   those found in the Health Promotion Service Evaluation and Impact
Study. In
   addition, Reynolds Electrical Stay Alive and Well program
participants
   experienced statistically-significant reductions in total serum
cholesterol
   levels (21 mg/dl) and weight (10 pounds). Although not statistically
   significant, participants also reduced their mean blood pressures by
an
   average of 4.0 mm Hg. Program cost per employee came to $76.24. After
2
   years, employee participants experienced 21 percent lower
lifestyle-related
   medical claims costs than nonparticipants. This resulted in a savings
of $
   127.89 per participant, and a benefit-to-cost ratio of 1.68:1.00.
Data
   suggested that the program consistently reduced employee health risk
   factors and paid health insurance claims for lifestyle-related
disease.

Sciacca, J.; Seehafer, R.; Reed, R.; Mulvaney, D.
"Impact of Participation in Health Promotion on Medical Costs: A
   Reconsideration of the Blue Cross and Blue Shield of Indiana Study."
American Journal of Health Promotion. 7(5):374-383, 395, May-June 1993.
Abstract
   Researchers investigated whether participation in a comprehensive
worksite
   health promotion program was associated with reduced employee health
care 
   costs within the Blue Cross and Blue Shield of Indiana corporate
   headquarters. Researchers identified four independent study groups,
two
   treatment and two comparison, based on type and date of first
participation
   in the intervention. Subjects were 743 men and women employed
continuously
   by the company throughout a 7-year period. The health promotion
program
   consisted of four progressive phases involving (1) health risk
reduction
   mass education, (2) completion of a health risk appraisal and risk
   reduction counseling, (3) health promotion classes such as smoking
   cessation and nutrition education, and (4) followup and maintenance.
   Researchers collected data on the number of intervention class
sessions
   attended by employees and recorded their participation in health risk
   appraisal and counseling activities, alcohol and drug interventions,
and
   nutrition, smoking, exercise, or weight reduction classes. The study
   created three sets of health care cost data: (1) The first set
included 7 
   years of data from all types of health care use including health
costs
   relating to pregnancy, congenital defect, and trauma; (2) the second
set
   included only health care costs from diseases likely to be related to
   individuals' behaviors and lifestyles (such as neoplasms, myocardial
   infarction, and emphysema); and (3) the third set consisted of the
   previously mentioned lifestyle-related health cost data excluding all
   neoplasm-related health costs. The principal dependent variable was
   preprogram to postprogram changes in health costs as measured by
employee 
   health care expense claims paid for by the company's health insurance
plan.
   Program evaluation showed that participation was not associated with
   reduced health care costs.

American Dietetic Association
Position of the American Dietetic Association: cost-effectiveness
of medical nutrition therapy. JADA 95(1):88-91, Jan. 1995.
Includes 46 references.

The following is an article CDC authored describing prevention
effectiveness:
Thacker SB.  Koplan JP.  Taylor WR.  Hinman AR.  Katz MF.  Roper WL.
"Assessing prevention effectiveness using data to drive program
decisions"
  Public Health Reports.  109(2):187-94, 1994 Mar-Apr.
Abstract
  The measure of the effectiveness of health promotion and disease
  prevention activities is the impact of prevention policies, programs,
and
  practices on public health and clinical medicine. Assessing prevention
  effectiveness involves continuing quantitative analysis of health
outcomes
  resulting from prevention practices. Additionally, assessment involves
  evaluation of disease- and injury-prevention activities, including
their
  medical, legal, ethical, and economic impacts. Although assessing the
  effectiveness of prevention activities involves measuring efficacy,
  safety, and cost, the primary criterion is to improve health at a
  reasonable cost, not merely to contain costs. Policy makers can use
the
  results of assessments to set priorities in public health. The authors
use
  case studies to illustrate various approaches to evaluating prevention
  programs, including programs for preventing measles, breast cancer,
and
  diabetic retinopathy. Rigorous evaluation of the effectiveness of
  prevention activities is essential to the wide acceptance of
preventive
  interventions and the willingness to pay for them.