Topic: Healthy Eating

Brief: CalFresh Fruit & Vegetable EBT Program in Santa Clara County

Young father taking his two kids shopping at a local co-op grocery store. The oldest is pointing at organic beets.

This material was developed at the Harvard T.H. Chan School of Public Health in collaboration with the County of Santa Clara Public Health Department through participation in the CalFresh Healthy Living-Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This material was funded by USDA’s Supplemental Nutrition Assistance Program, an equal opportunity provider. This material is intended for educational use only.  

This brief summarizes a CalFresh Healthy Living-CHOICES Project Learning Collaborative Partnership model examining the CalFresh (federally, the Supplemental Nutrition Assistance Program, SNAP) Fruit & Vegetable EBT program in Santa Clara County. This model examined the health impacts of expanding the CalFresh Fruit & Vegetable EBT Program throughout Santa Clara County. Read more in the full brief.

Contact choicesproject@hsph.harvard.edu with any accessibility questions.

Citation

Cholette V, Coxe N, Shir A, Gacutan-Galang J, Beccarelli M, Evans LW, Pugliese J, Gouck J, Barrett JL, McCulloch SM, Garrone ME, Xiao Y, Cradock AL. CalFresh Fruit & Vegetable EBT Program in Santa Clara County {Issue Brief}. County of Santa Clara Public Health Department, San José, CA, and the CalFresh Healthy Living-Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership; December 2025.

The design for this brief and its graphics were developed by partners at Headlands Marketing.

Learn more about the CalFresh Healthy Living CHOICES Project.

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Coffee Chat: Promoting Healthy Beverage Consumption Among School-Age Children & Adolescents: New Expert-Backed Recommendations

In this coffee chat hosted by the CHOICES Community of Practice, Megan Lott, Deputy Director of Healthy Eating Research at the Duke Global Health Institute, walked through these new recommendations and shared resources that can be used to provide guidance for parents, caregivers, and public health professionals.

View the resource round-up from this coffee chat

Download the March 2025 coffee chat presentation slides

Disclaimer: Our guest speakers share their own perspectives and do not speak for Harvard.

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Coffee Chat: Creating Healthier Spaces for Kids: A Walkthrough of OSNAP Resources for Out-of-School Time

In this coffee chat hosted by the CHOICES Community of Practice, Bekka Lee, Co-Investigator at the Prevention Research Center on Nutrition and Physical Activity & Lecturer in the Department of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health and Director of the Community Engagement Program at Harvard Catalyst, provided an in-depth overview of resources from the Out-of-School Nutrition and Physical Activity (OSNAP) initiative including a discussion of how you can implement this evidence-based intervention in your program, city, or state.

View the resource round-up from this coffee chat

Download the January 2025 coffee chat presentation slides

Disclaimer: Our guest speakers share their own perspectives and do not speak for Harvard.

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School-based nutrition education programs alone are not cost effective for preventing childhood obesity: a microsimulation study

This study aims to estimate the societal costs and potential for cost-effectiveness of 3 nutrition education curricula frequently implemented in United States public schools for childhood obesity prevention.

Kenney EL, Poole MK, McCulloch SM, Barrett JL, Tucker K, Ward ZJ, Gortmaker SL. School-based nutrition education programs alone are not cost effective for preventing childhood obesity: a microsimulation study. Am J Clin Nutr. 2025 Jan;121(1):167-173. doi: 10.1016/j.ajcnut.2024.11.006. Epub 2024 Nov 12.

Abstract

Background

Although interventions to change nutrition policies, systems, and environments (PSE) for children are generally cost effective for preventing childhood obesity, existing evidence suggests that nutrition education curricula, without accompanying PSE changes, are more commonly implemented.

Objectives

This study aimed to estimate the societal costs and potential for cost-effectiveness of 3 nutrition education curricula frequently implemented in United States public schools for childhood obesity prevention.

Methods

In 2021, we searched for nutrition education curricula in the Supplemental Nutrition Assistance Program (SNAP)-Ed Toolkit, a catalog of interventions for obesity prevention coordinated by the federal government. Standard costing methodologies estimated the societal costs from 2023 to 2032 of nationwide implementation of each identified curriculum. Using the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) microsimulation model, which projects the costs, health care costs saved, and cases of obesity prevented for childhood obesity prevention interventions, we conducted threshold analyses for each curriculum, estimating the cost per quality-adjusted life-year for a range of hypothetical effects on child BMI to determine how large of an effect each curriculum would need to have to meet a cost-effectiveness threshold of $150,000 per quality-adjusted life-year.

Results

Three nutrition education curricula without PSE were identified from SNAP-Ed; none had evidence of an impact on obesity risk. From 2023 to 2032, the estimated implementation costs of the curricula nationwide ranged from $1.80 billion (95% upper interval: $1.79, $1.82 billion) to $3.48 billion (95% upper interval: $3.44, $3.51 billion). Each curriculum would have to reduce average child BMI by 0.10 kg/m2 or more—an effect size that has not been reported by any of the 3 curricula, or by more comprehensive existing prevention programs—to be considered cost effective at this threshold.

Conclusions
SNAP-Ed–endorsed nutrition education curricula alone are unlikely to be cost effective for preventing childhood obesity. Continued efforts to implement interventions with strong evidence for effectiveness, including PSE approaches, are needed.

Keywords
childhood obesity; nutrition education; schools; prevention; cost-effectiveness analysis; threshold analysis


Funding

This study was supported by Healthy Eating Research, a national program of the Robert Wood Johnson Foundation (2833590), The JPB Foundation, the National Heart, Lung, and Blood Institute (NHLBI) (5T32HL098048, R01HL146625, and 1F31HL162250), the National Institute of Diabetes and Digestive and Kidney Diseases (K01DK125278), and the Centers for Disease Control and Prevention (U48DP006376). The content is solely the responsibility of the authors and does not necessarily represent the official views of these agencies.

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Coffee Chat: Cost-Effective Strategies to Create Healthier Environments: A Walkthrough of the CHOICES National Action Kit 2.0

In this coffee chat hosted by the CHOICES Community of Practice, Jessica Barrett, Senior Research Analyst at the Prevention Research Center on Nutrition and Physical Activity at the Harvard T.H. Chan School of Public Health, demonstrated how to use the CHOICES National Action Kit 2.0, highlighting the metrics that can be compared and where to find more detailed information about a strategy to support the planning and prioritization of health promotion efforts.

View the resource round-up from this coffee chat

Download the November 2024 coffee chat presentation slides

Disclaimer: Our guest speakers share their own perspectives and do not speak for Harvard.

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Coffee Chat: Creating Healthier Spaces for Kids: Promoting Healthy Eating, Physical Activity, & Health Equity in Out-of-School Time

In this coffee chat hosted by the CHOICES Community of Practice, Kate Goddard, Project Director for the Collaborative for Advancing Health Equity in Out-of-School Time at the Education Development Center, discussed how out-of-school time standards can be used to support health and well-being and highlighted examples of evidence-based strategies, including the Out-of-School Nutrition and Physical Activity (OSNAP) Initiative.

View the resource round-up from this coffee chat

Download the October 2024 coffee chat presentation slides


Disclaimer: Our guest speakers share their own perspectives and do not speak for Harvard.

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Cost-effectiveness of mandating calorie labels on prepared foods in supermarkets

This study determines the cost-effectiveness of the requirement for chain food establishments—including supermarkets—to display calorie labels on prepared (i.e., ready-to-eat) foods since 2018.

Grummon AH, Barrett JL, Block JP, McCulloch S, Bolton A, Dupuis R, Petimar J, Gortmaker SL. Cost-effectiveness of mandating calorie labels on prepared foods in supermarketsAm J Prev Med. 2024 Oct, doi: 10.1016/j.amepre.2024.10.007.

Abstract

Introduction

The US has required chain food establishments—including supermarkets—to display calorie labels on prepared (i.e., ready-to-eat) foods since 2018. Implementation of this supermarket calorie labeling policy reduced purchases of prepared foods from supermarkets, but it remains unknown whether the policy is cost-effective.

Methods

In 2023-2024, this study applied the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) microsimulation model to estimate the effects of the supermarket calorie labeling policy on health, costs, and cost-effectiveness over 10 years (2018-2027) for the US population. The model projected benefits overall and among racial, ethnic, and income subgroups. Sensitivity analyses varied assumptions about the extent to which consumers replace calorie reductions from prepared foods with calories from other sources (i.e., caloric compensation).

Results

From 2018-2027, the supermarket calorie labeling policy was projected to save $348 million in healthcare costs (95% Uncertainty Interval [UI]: $263-426 million), prevent 21,700 cases of obesity (95% UI: 18,200-25,400), including 3,890 cases of childhood obesity (95% UI: 2,680-5,120), and lead to 15,100 quality-adjusted life years (QALYs) gained across the US population (95% UI: 10,900-20,500). The policy was projected to prevent cases of obesity and childhood obesity across all racial, ethnic, and income groups. The policy was projected to be cost-saving when assuming low and moderate caloric compensation and cost-effective when assuming very high caloric compensation.

Conclusions

A policy requiring calorie labels on prepared foods in supermarkets was projected to be cost-saving or cost-effective and lead to reductions in obesity across all racial, ethnic, and income groups.

Keywords
calorie labels; food policy; cost-effectiveness; obesity; simulation


Funding

This research was supported in part by a grant from the National Institutes of Health (NIH) National Institute of Diabetes and Digestive and Kidney Diseases to Jason P. Block (R01 DK115492) and the NIH National Heart, Lung and Blood Institute at the National Institutes of Health (R01 HL14662501), the JPB Foundation (Grant no 1085) and the Centers for Disease Control and Prevention (CDC, U48 DP006376). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH, JPB Foundation, or CDC. The funders had no role in the study design; collection, analysis, or interpretation of the data; writing the manuscript; or the decision to submit the paper for publication.

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Strategy Profile: Policy to Promote Healthy Snacks & Beverages in Afterschool Programs (Healthy Snacks)

The information in this resource is intended only to provide educational information. This profile describes the estimated benefits, activities, resources, and leadership needed to implement a strategy to improve child health. This information can be useful for planning and prioritization purposes.

  • Policy adopted by afterschool programs to ensure that the snacks and beverages served to children in grades K-8 attending afterschool programs meet federal nutritional guidelines for afterschool snacks.

What population benefits?

Children ages 5-14 attending afterschool programs that participate in the National School Lunch Program or the Child and Adult Care Food Program.

What are the estimated benefits?

Relative to not implementing the strategy
Improve the nutritional quality of children’s snack and beverage offerings and, in turn, promote healthy child weight.

What are the additional benefits?

Relative to not implementing the strategy
The costs of implementing this strategy could be offset by savings from…
↓ Decrease in snack and beverage costs for families

What activities and resources are needed?

Activities Resources Who Leads?
Notify afterschool programs who participate in the National School Lunch Program or Child and Adult Food Program of the suggested policy change • Time for the afterschool program coordinating or licensing organization to develop mailings
• Printing and mailing costs
State Afterschool Program Administrators
Train Afterschool Program Staff on healthy snack and beverage policy • Time for afterschool program coordinating or licensing organization to develop online training about nutrition standards
• Time for Afterschool Program Staff to be trained
State Afterschool Program Administrators
Add snack policy to afterschool program policy handbook • Time for Afterschool Program Staff to write policy Afterschool Program Staff
Strategy Modification

This strategy could be implemented using an in-person train-the-trainer model, where training coordinators train and provide technical assistance to afterschool program supervisors, who then train their staff. The strategy could also be modified to include monitoring activities, which would require time for a coordinator to conduct regular monitoring visits or develop survey questions for afterschool program staff to assess compliance. Some state and local health agencies may choose to focus only on a healthy beverage policy that ensures that the only beverages available are those that meet the federal snack requirements, without setting requirements for foods.


FOR ADDITIONAL INFORMATION
Kenney EL, Austin SB, Cradock AL, et al. Identifying sources of children’s consumption of junk food in Boston after-school programs, April-May 2011. Prev Chronic Dis. 2014;11:E205. DOI: http://dx.doi.org/10.5888/pcd11.140301

Selected CHOICES research brief including cost-effectiveness metrics:
Pagnotta M, Hardy H, Burry K, Flax CN, Barrett JL, Cradock AL. Allegheny County: Supporting Healthy Food and Beverage Choices in Afterschool Programs {Issue Brief}. Allegheny County Health Department, Pittsburgh, PA, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; November 2019. Available at: https://choicesproject.org/publications/brief-healthysnacks-afterschool-allegheny-pa

Salas TM, Meinen A, Kim H, McCulloch S, Reiner J, Barrett J, Cradock AL. Wisconsin: Supporting Healthy Beverage Choices in Out-of-School Time Programs {Issue Brief}. Wisconsin Department of Health Services & University of Wisconsin-Madison, Madison, WI, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; May 2021. Available at: https://choicesproject.org/publications/brief-healthy-beverage-policy-wisconsin


Suggested Citation

CHOICES Strategy Profile: Policy to Promote Healthy Snacks and Beverages in Afterschool Programs (Healthy Snacks). CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; September 2024.

Funding

This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose. The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

Adapted from the TIDieR (Template for Intervention Description and Replication) Checklist

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Strategy Report: Sugary Drink Excise Tax: 2 Cents per Ounce

Mom and young daughter drinking glasses of water

The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose.

Overview

CHOICES uses cost-effectiveness analysis to compare the costs and outcomes of different policies and programs promoting improved nutrition or increased physical activity in schools, early care and education and out-of-school settings, communities, and clinics. This strategy report describes the projected national population reach, impact on health and health equity, implementation costs, and cost-effectiveness for an effective strategy to improve child health. This information can help inform decision-making around promoting healthy weight. To explore and compare additional strategies, visit the CHOICES National Action Kit 2.0.

Continue reading in the full report.

Contact choicesproject@hsph.harvard.edu with any accessibility questions.

Suggested Citation

Barrett JL, McCulloch SM, Cradock AL, Gortmaker SL. CHOICES National Action Kit: Sugary Drink Excise Tax: 2 Cents per Ounce Strategy Report. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; May 2024.

Acknowledgments

We thank the following members of the CHOICES Project team for their contributions: Molly Garrone, Dar Alon, Banapsha Rahman, Ya Xuan Sun, Amy Bolton, Jenny Reiner, Matt Lee, Zach Ward.

Funding

This work is supported by the National Institutes of Health (R01HL146625), The JPB Foundation, and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders. The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose

For further information, contact choicesproject@hsph.harvard.edu

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Strategy Report: Improved WIC Food Package for 1-4-Year-Olds (2009)

The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose.

Overview

CHOICES uses cost-effectiveness analysis to compare the costs and outcomes of different policies and programs promoting improved nutrition or increased physical activity in schools, early care and education and out-of-school settings, communities, and clinics. This strategy report describes the projected national population reach, impact on health and health equity, implementation costs, and cost-effectiveness for an effective strategy to improve child health. This information can help inform decision-making around promoting healthy weight. To explore and compare additional strategies, visit the CHOICES National Action Kit 2.0.

Continue reading in the full report.

Contact choicesproject@hsph.harvard.edu with any accessibility questions.

Suggested Citation

Barrett JL, Kenney EL, Cradock AL, Gortmaker SL. CHOICES National Action Kit: Improved WIC Food Package for 1-4-Year-Olds (2009) Strategy Report. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; May 2024.

Acknowledgments

We thank the following members of the CHOICES Project team for their contributions: Molly Garrone, Matt Lee, Zach Ward, Stephanie McCulloch.

Funding

This work is supported by the National Institutes of Health (R01HL146625), The JPB Foundation, and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders. The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose

For further information, contact choicesproject@hsph.harvard.edu

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