Cost and Cost-Effectiveness of Students for Nutrition and eXercise (SNaX)



      To examine the cost and cost-effectiveness of implementing Students for Nutrition and eXercise (SNaX), a 5-week middle school–based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education.


      Five intervention and 5 control middle schools (mean enrollment, 1520 students) from the Los Angeles Unified School District participated in a randomized controlled trial of SNaX. Acquisition costs for materials and time and wage data for employees involved in implementing the program were used to estimate fixed and variable costs. Cost-effectiveness was determined using the ratio of variable costs to program efficacy outcomes.


      The costs of implementing the program over 5 weeks were $5433.26 per school in fixed costs and $2.11 per student in variable costs, equaling a total cost of $8637.17 per school, or $0.23 per student per day. This investment yielded significant increases in the proportion of students served fruit and lunch and a significant decrease in the proportion of students buying snacks. The cost-effectiveness of the program, per student over 5 weeks, was $1.20 per additional fruit served during meals, $8.43 per additional full-priced lunch served, $2.11 per additional reduced-price/free lunch served, and $1.69 per reduction in snacks sold.


      SNaX demonstrated the feasibility and cost-effectiveness of a middle school–based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education. Its cost is modest and unlikely to be a significant barrier to adoption for many schools considering its implementation.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Academic Pediatrics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Institute of Medicine of the National Academies
        Nutrition Standards for Food in Schools: Leading the Way Toward Healthier Youth.
        Institute of Medicine of the National Academies, Washington, DC2007 (Available at: Accessed July 31, 2014)
        • Davis M.M.
        • Gance-Cleveland B.
        • Hassink S.
        • et al.
        Recommendations for prevention of childhood obesity.
        Pediatrics. 2007; 120: S229-S253
        • Wang Y.C.
        • McPherson K.
        • Marsh T.
        • et al.
        Health and economic burden of the projected obesity trends in the USA and the UK.
        Lancet. 2011; 378: 815-825
      1. How can healthier school snacks and beverages improve student health and help school budgets?2013 (Available at:) (Accessed July 31, 2014)
        • Cradock A.L.
        • McHugh A.
        • Mont-Ferguson H.
        • et al.
        Effect of school district policy change on consumption of sugar-sweetened beverages among high school students, Boston, Massachusetts, 2004–2006.
        Prev Chronic Dis. 2011; 8: A74
        • Hakim S.M.
        • Meissen G.
        Increasing consumption of fruits and vegetables in the school cafeteria: the influence of active choice.
        J Health Care Poor Underserved. 2013; 24: 145-157
        • Wang D.
        • Stewart D.
        The implementation and effectiveness of school-based nutrition promotion programmes using a health-promoting schools approach: a systematic review.
        Public Health Nutr. 2013; 16: 1082-1100
        • Institute of Medicine
        Schools Can Play a Role in Childhood Obesity Prevention.
        Institute of Medicine, Washington, DC2004 (Available at: Accessed July 31, 2014)
        • Bjelland M.
        • Bergh I.H.
        • Grydeland M.
        • et al.
        Changes in adolescents' intake of sugar-sweetened beverages and sedentary behaviour: results at 8 month mid-way assessment of the HEIA study—a comprehensive, multi-component school-based randomized trial.
        Int J Behav Nutr Phys Act. 2011; 8: 63
        • Gortmaker S.L.
        • Peterson K.
        • Wiecha J.
        • et al.
        Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health.
        Arch Pediatr Adolesc Med. 1999; 153: 409-418
        • Singh A.S.
        • Chin A.P.M.J.
        • Brug J.
        • et al.
        Dutch obesity intervention in teenagers: effectiveness of a school-based program on body composition and behavior.
        Arch Pediatr Adolesc Med. 2009; 163: 309-317
        • Taber D.R.
        • Chriqui J.F.
        • Perna F.M.
        • et al.
        Weight status among adolescents in states that govern competitive food nutrition content.
        Pediatrics. 2012; 130: 437-444
        • Brown H.S.
        • Pérez A.
        • Li Y.P.
        • et al.
        The cost-effectiveness of a school-based overweight program.
        Int J Behav Nutr Phys Activity. 2007; 4: 47
        • Kesztyüs D.
        • Schreiber A.
        • Wirt T.
        • et al.
        Economic evaluation of URMEL-ICE, a school-based overweight prevention programme comprising metabolism, exercise and lifestyle intervention in children.
        Eur J Health Econ. 2013; 14: 185-195
        • Li Y.W.
        • Yang Q.
        • Lowry R.
        • et al.
        Economic analysis of a school-based obesity prevention program.
        Obes Res. 2003; 11: 1313-1324
        • Wang L.Y.
        • Gutin B.
        • Barbeau P.
        • et al.
        Cost-effectiveness of a school-based obesity prevention program.
        J Sch Health. 2008; 78: 619-624
      2. Healthy Rewards: Selling healthy snack foods and beverages can be profitable. 2012 (Available at:) (Accessed July 31, 2014)
      3. Budget cuts reach bone for Philadelphia schools. New York Times, June 17, 2013. Available at: Accessed July 31, 2014.

      4. Budget cuts may threaten city programs for children. New York Times, March 5, 2012. Available at: Accessed July 31, 2014.

        • Board on Children, Youth, and Families
        • Institute of Medicine
        • National Research Council
        Considerations in Applying Benefit–Cost Analysis to Preventive Interventions for Children, Youth, and Families: Workshop Summary.
        National Academies Press, Washington, DC2014 (Available at: Accessed July 31, 2014)
        • Bogart L.M.
        • Cowgill B.O.
        • Elliott M.N.
        • et al.
        A randomized controlled trial of students for nutrition and exercise: a community-based participatory research study.
        J Adolesc Health. 2014; 3: 415-422
        • Gold M.R.
        • Siegel J.E.
        • Russell L.B.
        Cost-Effectiveness in Health and Medicine.
        Oxford University Press, New York, NY1996
        • Ladapo J.A.
        • Elliott M.N.
        • Bogart L.M.
        • et al.
        Cost of talking parents, healthy teens: a worksite-based intervention to promote parent-adolescent sexual health communication.
        J Adolesc Health. 2013; 53: 595-601
        • Drummond M.F.
        Methods for the Economic Evaluation of Health Care Programmes.
        3rd ed. Oxford University Press, New York2005
        • Hosmer D.W.
        • Lemeshow S.
        • May S.
        Applied Survival Analysis: Regression Modeling of Time-to-Event Data.
        2nd ed. Wiley-Interscience, Hoboken, NJ2008
        • Centers for Disease Control and Prevention
        Vital signs: obesity among low-income, preschool-aged children-United States, 2008–2011.
        MMWR Morb Mortal Wkly Rep. 2013; 62: 629
      5. Fryar CD, Carroll MD, Ogden CL. Prevalence of obesity among children and adolescents: United States, trends 1963–1965 through 2009–2010. National Center for Health Statistics Health E-Stat. September 2012. Available at: Accessed August 8, 2015.

        • Ogden C.L.
        • Carroll M.D.
        • Kit B.K.
        • et al.
        Prevalence of obesity and trends in body mass index among US children and adolescents, 1999–2010.
        JAMA. 2012; 307: 483-490
        • Reilly J.J.
        • Methven E.
        • McDowell Z.C.
        • et al.
        Health consequences of obesity.
        Arch Dis Child. 2003; 88: 748-752
        • Baker J.L.
        • Olsen L.W.
        • Sorensen T.I.
        [Childhood body mass index and the risk of coronary heart disease in adulthood].
        Ugeskr Laeger. 2008; 170: 2434-2437
        • Hannon T.S.
        • Rao G.
        • Arslanian S.A.
        Childhood obesity and type 2 diabetes mellitus.
        Pediatrics. 2005; 116: 473-480
        • te Velde S.J.
        • Twisk J.W.
        • Brug J.
        Tracking of fruit and vegetable consumption from adolescence into adulthood and its longitudinal association with overweight.
        Br J Nutr. 2007; 98: 431-438
        • Cawley J.
        • Meyerhoefer C.
        The medical care costs of obesity: an instrumental variables approach.
        J Health Econ. 2012; 31: 219-230
        • Withrow D.
        • Alter D.A.
        The economic burden of obesity worldwide: a systematic review of the direct costs of obesity.
        Obes Rev. 2011; 12: 131-141