Benefits of Nutrition education and intervention
sak2 at cdc.gov
Mon Dec 22 09:08:00 PST 1997
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.
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
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.
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:
cost-effectiveness analysis was made from data from the literature and
Coronary Heart Disease Policy Model and was based on the US population
35 to 84 years. Study interventions were populationwide programs to
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
projected cost divided by the change in projected life-years when the
population receives the intervention compared with the population
the intervention. A populationwide program with the costs ($4.95 per
person per year) and cholesterol-lowering effects (an average 2%
in serum cholesterol levels) of the Stanford Five-City Project would
prolong life at an estimated cost of only $3200 per year of life
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
save resources under many scenarios, especially if the program
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.
OBJECTIVES. The aim of this study was to carry out a
analysis of a multifactorial intervention programme in treated
hypertensive patients. DESIGN. A cost-effectiveness analysis based on
years of follow-up in an open, randomized, parallel-group study with
allocation either to a comprehensive, multiple-risk factor
programme or to conventional treatment. SETTING. An outpatient clinic
city hospital. SUBJECTS. Inclusion criteria were: male sex, age 50-72
(mean 66.4) years, treated hypertension and at least one of the
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
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
HbAlc < 6.0% and diastolic blood pressure < 90 mmHg in both groups.
OUTCOME MEASURE. Incremental cost per life-year gained of the
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
interventions." Health Education Quarterly. 22(1):9-19, 1995 Feb.
We used outcome data from a randomized work site intervention trial to
examine the cost-effectiveness of four cardiovascular disease (CVD)
reduction programs: health risk assessment (HRA), risk factor
(RFE), behavioral counseling (BC), and behavioral counseling plus
incentives (BCI). Composite CVD risk scores were derived from measures
serum total cholesterol, blood pressure, number of cigarettes smoked,
mass index, and aerobic capacity. The economic evaluation of the
focused on the subset of costs most sensitive to the differences
the interventions, and a sensitivity analysis examined some of the
relevant cost variations. At the 6-month follow-up (i.e., the "action"
initiation stage of lifestyle change), the RFE, BC, and BCI
produced a significant reduction in cardiovascular risk. Incremental
analyses demonstrated RFE to be more cost-effective, but not as
effective as BC; BC was more cost-effective than RFE when assessment
were included, and BCI was judged to be the least cost-effective. At
12-month follow-up (i.e., the "maintenance" stage of lifestyle of
BC was the only program found to produce a significant reduction in
risk. Individualized behavioral counseling was found to be a
cost-effective strategy for the initiation and maintenance of CVD risk
Lovato, C.Y.; Green, L.W.; Stainbrook, G.L.
"Benefits Anticipated by Industry in Supporting Health Promotion
the Worksite" in Economic Impact of Worksite Health Promotion.
Opatz, J.P.; ed.
Champaign, IL, Human Kinetics Publishers, pp. 3-31, 1994.
Benefits Anticipated by Industry in Supporting Health Promotion
the Worksite, a book chapter in Economic Impact of Worksite Health
Promotion, examines the growth of the worksite health promotion
assesses the rationale and experience behind three programs adopted
industry, and attempts to account for the diffusion of programs among
employers. Epidemiological importance and the demonstrated
interventions were criteria used by the Public Health Service to
national priorities in health promotion. Common criteria used in
health promotion priorities for worksite health promotion included
cost-benefit and cost-effectiveness considerations, (2) prior
of benefits in comparable sites, (3) time frame for the realization
benefits, (4) relevance of the program to health costs and risks in
company, (5) employee interest in the program, and (6) possible
effects of the program. The work setting represents the single most
important channel to systematically reach the adult population
health information and health promotion programs. A 1986 survey
by the U.S. Department of Health and Human Services found that the
frequently cited categories of worksite health promotion activities
included (1) smoking control, (2) health risk assessment, (3) back
prevention and care, (4) stress management, (5) exercise and fitness,
off-the-job accident prevention, (7) nutritional education, (8) blood
pressure control, and (9) weight control. The worksite health
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
increased physical activity, including fitness programs. Researchers
that worksite health programs were increasing because they (1) were
with employees; (2) supplied management with positive, constructive,
relatively low-cost benefits for employees; (3) improved both health
productivity indicators in the short term; and (4) reduced medical
expenditures in the long term.
Whitmer, R.W.; Hilyer, J.C.; Brown, K.C.
"Medical Benefits Cost Containment: The Municipal Government of
Alabama" in Economic Impact of Worksite Health Promotion. Opatz,
Champaign, IL, Human Kinetics Publishers, pp. 177-191, 1994.
Medical Benefits Cost Containment: The Municipal Government of
Alabama, a book chapter in Economic Impact of Worksite Health
discusses the findings of an experimental cost-containment project.
on results of a 1-year pilot program, the basic project design for
year program included an annual medical screening, aggressive
referral, and health education and intervention programs addressing
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
approximately 95 percent of full-time employees participated annually
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
of the program at no cost; (2) group B also had free and total
except that spouses could not participate; (3) group C was permitted
participate in weight-control and exercise interventions only and
could participate; and (4) group D served as the control group.
among the groups included (1) the cost of medical care, (2) number of
hospital admissions, (3) number of physician visits, (4) number of
of major disease diagnoses, (5) measurable lifestyle changes, (6)
and type of medical problems that occur in those perceived to be less
healthy, (7) the effect of dependent participation, (8) effectiveness
regular and supervised exercise, (9) absenteeism due to illness, (10)
turnover, and (11) feelings of well-being and job satisfaction.
showed that (1) over the 5-year period, the city held its employer
costs constant while medical benefit costs for the average employer
United States doubled; (2) 13 percent of the employees had medical
serious enough to require referral to a physician; (3) approximately
percent of the employees did not have a regular doctor, and only 17
wanted help in finding a regular doctor; (4) the average time since
last doctor visit was 35 months; and (5) for the 5-year period,
medical benefits expenses were 21.1 percent below the national, per-
"LIVE FOR LIFE Program of Johnson and Johnson: Direct and Indirect
Benefits" in Economic Impact of Worksite Health Promotion. Opatz,
Champaign, IL, Human Kinetics Publishers, pp. 209-228, 1994.
LIVE FOR LIFE Program of Johnson and Johnson: Direct and Indirect
Benefits, a book chapter in Economic Impact of Worksite Health
discusses direct and indirect benefits of the Live for Life worksite
promotion program at Johnson and Johnson. The Live for Life system of
programs encompassed (1) a wellness program, (2) an occupational
program, (3) the medical portion of the employee benefit plan, (4)
employee assistance program, and (5) the safety program. All
encouraged to take a nurse-administered health profile that includes
behavioral; attitudinal; and biometric measures (e.g., blood
blood lipids, body fat, height and weight, and submaximal exercise
. Employees participate in a 3-hour lifestyle seminar. The core of
lifestyle improvement activities included behaviorally oriented
dealing with (1) nutrition, (2) exercise, (3) weight control, (4)
cessation, (5) stress management, and (6) blood pressure control. To
evaluate the program's intervention impact, researchers maintained
quasi-experimental design of the study for 2 years among two sets of
Johnson and Johnson manufacturing plants that were located within a
radius of each other and had comparable demographics and job-class
distributions. Some plants introduced the entire Live for Life
2,600 employees, while three companies offered only the health
component to 1,700 employees. Preliminary findings after the first 12
months indicated that, compared to the control group, the Life for
group showed improvement in (1) weight control, (2) exercise, (3)
pressure control, (4) percent body weight above ideal body weight,
cigarette smoking cessation, and (6) self-reported sick days.
costs for the Live for Life groups grew at a significantly lower rate
did those for the control group, on average $43 and $42 a year for
study groups compared with $76 for the control group. Intervention
costs in constant dollars approximately doubled during the 5-year
period, compared with the 4-fold increase that occurred in costs for
control group; this equaled $245,079 a year for the Live for Life
Johannesson, M.; Agewall, S.; Hartford, M.; Hedner, T.; Fagerberg, B.
"Cost-effectiveness of a Cardiovascular Multiple-risk-factor
Programme in Treated Hypertensive Men"
Journal of Internal Medicine. 237(1):19-26, January 1995.
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
treatment costs minus saved costs of reduced cardiovascular
the multifactorial treatment program divided by the increased number
life-years gained compared with the conventional drug treatment.
Researchers used a treatment duration of 3 years to estimate the
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
than or equal to 6.5 mmol L, and/or smoking, and/or diabetes
intervention included individual advice and group meetings based on
nutritional advice and behavioral treatment principles, and use of
therapy as necessary. Researchers conducted estimations based on
the risk factors. After 3 years' followup, the change in total
and smoking had statistical significance at the 5 percent level. The
in diastolic blood pressure was statistically significant after 1
but not after 3 years' followup. The extra costs for the 3 years of
intervention program came to about SEK 5,000 per patient. The cost
life-year gained came to SEK 4,000 based on the observed risk
and ranged between SEK 62,000 and SEK 163,000 in three estimations
the risk factor changes. Findings indicated the cost-effectiveness of
intervention in the studied population. 5 tables, 33 references.
Report by Anthem Health Systems:
"Staying Alive and Well at Reynolds Electrical and Engineering Company,
Indianapolis, IN, Anthem Health Systems, 45 p., 1993.
(Anthem Health Systems, 5451 West Lakeview Parkway South Drive,
Indianapolis, IN 46268)
Staying Alive and Well at Reynolds Electrical and Engineering
case study of the results of the Stay Alive and Well program
Reynolds Electrical and Engineering Company in Las Vegas, Nevada,
1988-1989. It compares the results to those of the Health Promotion
Evaluation and Impact Study conducted at Blue Cross and Blue Shield
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
program added other topics, including back care, breast health,
management, skin cancer, heart health, cardiopulmonary resuscitation
and acquired immunodeficiency syndrome (AIDS) in the workplace. To
the program, Reynolds Electrical staff collected data at 6-month
on program participation rates, outcome measures, health risk
insurance utilization data, and program costs. Program participation
were approximately 51 percent, and intervention program completion
ranged from 56 percent to 80 percent. These rates equalled or
those found in the Health Promotion Service Evaluation and Impact
addition, Reynolds Electrical Stay Alive and Well program
experienced statistically-significant reductions in total serum
levels (21 mg/dl) and weight (10 pounds). Although not statistically
significant, participants also reduced their mean blood pressures by
average of 4.0 mm Hg. Program cost per employee came to $76.24. After
years, employee participants experienced 21 percent lower
medical claims costs than nonparticipants. This resulted in a savings
127.89 per participant, and a benefit-to-cost ratio of 1.68:1.00.
suggested that the program consistently reduced employee health risk
factors and paid health insurance claims for lifestyle-related
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.
Researchers investigated whether participation in a comprehensive
health promotion program was associated with reduced employee health
costs within the Blue Cross and Blue Shield of Indiana corporate
headquarters. Researchers identified four independent study groups,
treatment and two comparison, based on type and date of first
in the intervention. Subjects were 743 men and women employed
by the company throughout a 7-year period. The health promotion
consisted of four progressive phases involving (1) health risk
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
attended by employees and recorded their participation in health risk
appraisal and counseling activities, alcohol and drug interventions,
nutrition, smoking, exercise, or weight reduction classes. The study
created three sets of health care cost data: (1) The first set
years of data from all types of health care use including health
relating to pregnancy, congenital defect, and trauma; (2) the second
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
health care expense claims paid for by the company's health insurance
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
Thacker SB. Koplan JP. Taylor WR. Hinman AR. Katz MF. Roper WL.
"Assessing prevention effectiveness using data to drive program
Public Health Reports. 109(2):187-94, 1994 Mar-Apr.
The measure of the effectiveness of health promotion and disease
prevention activities is the impact of prevention policies, programs,
practices on public health and clinical medicine. Assessing prevention
effectiveness involves continuing quantitative analysis of health
resulting from prevention practices. Additionally, assessment involves
evaluation of disease- and injury-prevention activities, including
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
results of assessments to set priorities in public health. The authors
case studies to illustrate various approaches to evaluating prevention
programs, including programs for preventing measles, breast cancer,
diabetic retinopathy. Rigorous evaluation of the effectiveness of
prevention activities is essential to the wide acceptance of
interventions and the willingness to pay for them.
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