Nutrition education, especially for children, has been frequently implemented as a chronic disease prevention strategy, especially as a strategy for preventing obesity by modifying individual behaviors.(1) As the prevalence of childhood obesity has grown, so too have calls to implement more robust nutrition education curricula in K-12 school settings.(2–4) The Centers for Disease Control and Prevention promotes nutrition education as a chronic disease prevention strategy,(5) and $464 million of funding for the Supplemental Nutrition Assistance Program (SNAP), the largest social safety net program in the U.S., was set aside in 2022 for SNAP-Ed,(6) a program that promotes nutrition education for SNAP recipients and obesity prevention.(7) Yet education is typically much less effective at producing clinically meaningful and lasting change than public health interventions that modify contexts and environments using policy or systems changes.(8) While SNAP-Ed has, in recent years, also adopted “policies, systems and environment,” or PSE, strategies per requirements of the Healthy, Hunger-Free Kids Act of 2010,(7) its primary activity remains delivering direct nutrition education.(9,10)

It is unknown, however, whether direct nutrition education is a cost-effective strategy for population health. Although nutrition education may be a more palatable public health intervention for policymakers and politicians,(1) existing evidence suggests that, consistent with theoretical models proposing that education-only has limited impact compared to more robust, structural public health interventions,(8) nutrition education alone may have limited impact in supporting sustained behavior change with regards to eating and physical activity.(11–13) Meanwhile, school-based PSE strategies have been found to reduce childhood obesity risk (such as changes to school nutrition standards,(14) eliminating the sale of sugary beverages and other unhealthy snacks,(15) providing water on school lunch lines,(16) and incorporating more robust physical activity programs(17)). With the lack of evidence for effectiveness at reducing excess weight gain in children, it is not possible to directly estimate the cost-effectiveness of nutrition education curricula for childhood obesity prevention. Yet, given that nutrition education is widely promoted and adopted in U.S. schools as an obesity prevention strategy, it is important to understand its potential for cost-effectiveness, and whether the current widespread adoption of this strategy is a prudent use of existing school and public health funds.

The first aim of this study was to identify evidence-based nutrition education curricula that are currently promoted for youth obesity prevention in U.S. school settings and to estimate the implementation costs of these nutrition education curricula if they were scaled to reach students nationally. The second aim was to assess the potential for the nutrition education curricula to be cost-effective for childhood obesity prevention, by estimating how large of an average effect on children’s body mass index (BMI) each curriculum would need to have in order for it to meet a standard cost-effectiveness threshold.

The three direct nutrition education interventions included in this study–Pick a Better Snack, Harvest of the Month, and Choose Health: Food, Fun and Fitness– were projected to reach a large number of children. Over ten years, implementation of such nutrition education curricula would be estimated to reach between 31.7 million (95% UI: 31.0 million to 32.2 million) young children for Harvest of the Month to 34.0 million (95% UI: 33.5 million to 34.7 million) for Choose Health: Food, Fun, and Fitness (Table 1). Variations in projected reach were largely due to some interventions pertaining to smaller ranges of grade levels than others.

The interventions ranged widely in estimated total implementation costs. Harvest of the Month was estimated to cost $1.80 billion (95% UI: $1.79 billion to $1.82 billion) over ten years if implemented nationwide, with an annual cost per child of $18.70 ($18.50 to $18.90), while Choose Health, Fun, Food, and Fitness would cost $1.92 billion total (95% UI: $1.92 billion to $1.92 billion), with an annual cost per child of $15.90 ($15.60 to $16.20). Meanwhile, Pick a Better Snack, which involved more materials for more frequent lessons and more labor time for nutrition educators and school teachers(45) was estimated to have the highest implementation costs, at $3.48 billion (95% UI: $3.44 billion to $3.51 billion) over ten years and an annual cost per child of $30.50 ($30.20 to $30.90) (Table 1). Most of these implementation costs would be borne by state government agencies, with smaller costs borne by schools themselves, if the interventions were implemented with the same structures described in available evidence (Table 2).

When the curricula were assumed to have a BMI effect of −0.01 kg/m², the costs per QALY gained for each were well above a cost-effectiveness threshold of $150,000 per QALY ($1,430,000 per QALY for Pick a Better Snack, $1,060,000 per QALY for Harvest of the Month, and $950,000 per QALY for Choose Health, Fun, Food, and Fitness). Costs per QALY gained were still estimated to be higher than $150,000 for all curricula when a larger BMI effect of −0.05 kg/m² was assumed, and only met this threshold when a BMI effect of −0.1 kg/m² was used (Figure 2).

In this cost-effectiveness analysis of nutrition education curricula without any accompanying changes to policies, systems, or environments that were selected from the SNAP-Ed Toolkit for obesity prevention, we found that such curricula are unlikely to be cost-effective for preventing childhood obesity at a cost-effectiveness threshold of $150,000 per QALY. In order to be considered cost-effective, these interventions, which currently lack published evidence of having an effect on weight status, would need to have implausibly large effects on children’s BMI. We estimated that the effects of the curricula on students’ BMI would have to be greater than −0.05 kg/m², and at least −0.1 kg/m² for Pick a Better Snack, the curriculum with the highest estimated per person implementation cost, for the curricula to be cost-effective at $150,000 per QALY gained. In comparison, the Texas Sprouts intervention, which involved both school-based nutrition education and gardening, was associated with a nonsignificant BMI change of −0.02 kg/m².(46) Achieving a BMI effect two and a half to five times larger than that found by the Texas Sprouts intervention by implementing nutrition education alone is not likely to be plausible. While school-based nutrition education curricula may appear to be more feasible or politically palatable compared to more effective obesity prevention interventions that directly influence nutrition environments for children, and while nutrition education curricula may improve knowledge, the results of this study suggest that only implementing such curricula without accompanying PSE changes is likely not an efficient use of resources if obesity prevention is the goal.(8)

These findings highlight an area of public health nutrition practice that needs refinement. Public health agencies have scarce resources, experiencing regular budget cuts(47) and limited funds at state and local levels,(48) and local health departments across the US, for example, spend an average of roughly $50 per capita per year across all public health initiatives.(48) State public health departments and schools, which would likely bear a substantial portion of implementation costs, are also chronically under-resourced. In this context, it is even more essential for these entities to spend such limited resources wisely if the goal is measurable impacts in improving child weight status and reducing chronic disease burden. Cost-effectiveness analyses of school-based or afterschool-based obesity prevention programs that do involve the implementation of other components, such as Planet Health,(49) the Coordinated Approach to Child Health,(50) and the FitKid Project,(51) as well as analyses of school-based programs that solely focus on policy and environmental changes and do not incorporate nutrition education, like stronger standards for school meals,(24) and the provision of water dispensers on school lunch lines,(37) suggest that these approaches are simply more cost-effective. Nutrition professionals involved in supporting school-based efforts to promote healthy weight should consider selecting programs that focus on policy, systems, and environmental changes.

Of note, the modeled programs were identified via the SNAP-Ed toolkit, which serves as a mechanism for disseminating obesity prevention interventions to low income communities. In 2022, the federal government allocated $464 million to deliver SNAP-Ed in income-eligible communities nationwide,(6) much of which occurs in educational settings.(9) Prior evidence suggests more states are partnering with schools for PSE interventions(9) though barriers to implementation remain.(10,52–54) Our results suggest that if these school-based lessons involved the utilization of direct nutrition education-only programs, and do not make continued progress on PSE interventions, this approach may not be an investment with good value for money if childhood obesity prevention is the goal. This is of particular concern given that SNAP-Ed is meant to focus on low income communities; spending scarce financial resources on programs that are unlikely to impact obesity may inadvertently contribute to health inequities by diverting needed resources away from potentially effective programs instead. While school-based nutrition education alone may be helpful for improving students’ nutrition knowledge,(55) especially when multi-component interventions are implemented,(56,57) and for contributing to students’ development of general knowledge more broadly, such increases in knowledge may not be sufficient to translate to sustained behavioral change, particularly enough to bring about the significant dietary changes that may be necessary to prevent obesity in childhood.(58,59)

These results also further highlight the inadequacy of current efforts to translate the evidence base for childhood obesity into effective practice. Effective interventions have been identified,(60) and the cost-effectiveness of several school-based interventions in the U.S. has also been evaluated;(37,49–51) in other words, evidence does exist that could be used to help inform strategic choices that maximize the utilization of limited public health and educational expenditures for the most population health impact. Yet existing data suggests that such evidence is not being widely accessed in school settings.(61) More work to effectively disseminate research findings to practitioners in a usable, practical format is needed, as is work to help train practitioners in the skills needed for utilizing evidence-based interventions specific to their targeted health outcomes. Resources like the SNAP-Ed Toolkit Literature Review Database released in 2022(18) (now available in the SNAP-Ed Library(62)) may further assist practitioners with accessing evidence for dietary and obesity outcomes. More work may also be needed to ensure the implementation of multiple evidence-based interventions in schools as no single strategy or intervention will adequately prevent childhood obesity—careful consideration of cost-effectiveness is key to maximizing impact with available resources.

This study has several limitations. First, we were not able to directly estimate the cost-effectiveness of each of the curricula, since there were no published studies evaluating their effects on children’s weight status. Our threshold analysis assesses the plausibility of the interventions being cost-effective, but it is possible that the true, unstudied effect of the interventions are unexpectedly higher than what has been seen in similar interventions with larger doses and more intervention activities. Second, the nutrition education curricula assessed here have demonstrated effects on other behavioral outcomes (e.g. fruit and vegetable intake) for which there is no evidence of impact for childhood obesity/weight outcomes but may have other benefits for population health. Additionally, there are likely a multitude of other nutrition education curricula in use nationwide—some evidence-based, and some developed ad hoc—so the three curricula modeled here may not be representative of all programs in place at the moment. However, given that the three curricula modeled here were rigorously and carefully developed by experts in the field, and promoted by SNAP-Ed, it is unlikely that curricula developed ad hoc or with a less rigorous process would be more effective at preventing obesity than what was modeled.

By themselves, nutrition education curricula—even those endorsed by SNAP-Ed—are not likely to be cost-effective strategies for preventing childhood obesity. To be considered cost-effective at standard thresholds, each of these evidence-based nutrition education curricula would have to have implausibly large impacts on child BMI. While nutrition education can support improved knowledge and skills, it cannot be thought of as a stand-alone solution for addressing cardiometabolic disease risk in children. Efforts to better translate research findings on effective and cost-effective programs for childhood obesity prevention into public health practice are needed.