Washington State Institute for Public Policy
Preschool programs to create a healthy food environment and increase physical activity
Public Health & Prevention: School-based
Benefit-cost estimates updated May 2017.  Literature review updated November 2015.
A wide variety of interventions were used in the preschool programs that we reviewed. These included nutrition education for children and parents, additional time engaged in physical activity, and healthier snacks and drinks during the school day. The interventions were conducted in preschools serving children three to six years old.
BENEFIT-COST
META-ANALYSIS
CITATIONS
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2016). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $4 Benefits minus costs ($350)
Participants $12 Benefit to cost ratio ($0.40)
Others $6 Chance the program will produce
Indirect ($121) benefits greater than the costs 46 %
Total benefits ($99)
Net program cost ($250)
Benefits minus cost ($350)
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Labor market earnings associated with obesity $6 $14 $0 $1 $22
Health care associated with obesity ($2) ($2) $6 $3 $4
Adjustment for deadweight cost of program $0 $0 $0 ($125) ($125)
Totals $4 $12 $6 ($121) ($99)
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $247 2014 Present value of net program costs (in 2016 dollars) ($250)
Comparison costs $0 2014 Cost range (+ or -) 20 %
The programs in this analysis added 123 additional hours of physical activity or nutrition curriculum; we assume that these occur within a single school year. We assumed there was a maximum of 20 students per class and an adult-to-child ratio of 1:10. The per-student cost of the intervention was calculated by multiplying the per-student staff hours required by two staff members whose compensation were the average salary and benefits of a preschool teacher in 2014 in Washington State reported by the Bureau of Labor Statistics.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Primary or secondary participant No. of effect sizes Treatment N Adjusted effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Obesity 12 4490 -0.140 0.039 6 0.000 0.101 8 -0.140 0.001
Citations Used in the Meta-Analysis

Bayer, O., von Kries, R., Strauss, A., Mitschek, C., Toschke, A. M., Hose, A. et al. (2009). Short- and mid-term effects of a setting based prevention program to reduce obesity risk factors in children: a cluster-randomized trial. Clinical Nutrition, 28, 122-128.

De Bock, F., Breitenstein, L., & Fischer, J. E. (2012). Positive impact of a pre-school-based nutritional intervention on children's fruit and vegetable intake: results of a cluster-randomized trial. Public Health Nutrition, 15(3), 466-475.

Eliakim, A., Nemet, D., Balakirski, Y., & Epstein, Y. (2007). The effects of nutritional-physical activity school-based intervention on fatness and fitness in preschool children. Journal of Pediatric Endocrinology & Metabolism, 20(6), 711-718.

Fitzgibbon, M.L., Stolley, M.R., Schiffer, L., Van Horn, L., KauferChristoffel, K., & Dyer, A. (2005). Two-year follow-up results for Hip-Hop to Health Jr.: a randomized controlled trial for overweight prevention in preschool minority children. The Journal of pediatrics, 146(5), 618-625.

Fitzgibbon, M.L., Stolley, M.R., Schiffer, L., Van, H.L., Kauferchristoffel, K., Dyer, A. (2006). Hip-Hop to Health Jr. for Latino Preschool Children. Obesity, 14(9), 1616.

Fitzgibbon, M.L., Stolley, M.R., Schiffer, L.A., Braunschweig, C.L., Gomez, S.L., Van, H.L., & Dyer, A.R. (2011). Hip-Hop to Health Jr. Obesity Prevention Effectiveness Trial: postintervention results. Obesity, 19(5), 994-1003.

Jouret, B., Ahluwalia, N., Dupuy, M., Cristini, C., Nègre-Pages, L., Grandjean, H., & Tauber, M. (2009). Prevention of overweight in preschool children: results of kindergarten-based interventions. International Journal of Obesity, 33(10), 1075-1083.

Nemet, D., Geva, D., Pantanowitz, M., Igbaria, N., Meckel, Y., & Eliakim, A. (2011). Health promotion intervention in Arab-Israeli kindergarten children. Journal of Pediatric Endocrinology & Metabolism, 24(11-12), 1001-1007.

Nemet, D., Geva, D., & Eliakim, A. (2011). Health Promotion Intervention in Low Socioeconomic Kindergarten Children. The Journal of Pediatrics, 158(5), 796-801.

Puder, JJ, Marques-Vidal, P, Schindler, C, Zahner, L, Niederer, I, Bürgi, F, Ebenegger, V, ... Kriemler, S. (2011.). Effect of multidimensional lifestyle intervention on fitness and adiposity in predominantly migrant preschool children (Ballabeina): cluster randomised controlled trial. BMJ, 343, d6195.

Reilly, J.J., Kelly, L., Montgomery, C., Williamson, A., Fisher, A., McColl, J.H., ... & Grant, S. (2006). Physical activity to prevent obesity in young children: cluster randomised controlled trial. BMJ, 333(7577), 1041-3.

Zask, A., Adams, J.K., Brooks, L O., & Hughes, D F. (2012). Tooty Fruity Vegie: an obesity prevention intervention evaluation in Australian preschools. Health Promotion Journal of Australia, 23(1), 10-5.

For more information on the methods
used please see our Technical Documentation.
360.664.9800
institute@wsipp.wa.gov