R E S E A R C H A RT I C L E
...............................................................................................
Cost-Benefit Analysis Indicates the Positive Economic Benefits of the
Expanded Food and Nutrition Education Program Related to Chronic
Disease Prevention
R A D H I K A R A J G O PA L , P H D; 1 R U B Y H. C OX , P H D, RD; 2 M I C H A E L L A M B U R , P H D; 3
E DW I N C. L E W I S , M S 4
1
Indiana Center for Evaluation, Indiana University, Bloomington, Indiana 47408-2601; 2Department of Human
Nutrition, Foods, and Exercise,Virginia Polytechnic Institute and State University, Blacksburg,Virginia 24061;
3
Virginia Cooperative Extension,Virginia Polytechnic Institute and State University, Blacksburg,Virginia 24061;
4
Virginia Tech, Blacksburg,Virginia 24061
Implications: The results of EFNEP intervention translate
into a positive cost-benefit based on potential prevention of
diet-related chronic diseases and conditions.Thus, EFNEP is a
good use of federal tax dollars.
ABSTRACT
Objective: To provide an estimated cost-benefit ratio for the
Expanded Food and Nutrition Education Program (EFNEP),
based on potential prevention of diet-related chronic diseases
and conditions.
KEY WORDS: Expanded Food and Nutrition Education
Program (EFNEP), cost-benefit analysis, economic evaluation,
nutrition education evaluation, chronic disease, benefit-cost
ratio
Design: A retrospective cost-benefit study using demographic,
food/nutrient intake, and food-related behavioral data previously collected on program participants by trained paraprofessionals, before and after an intervention. Actual costs of implementing EFNEP for 1 year (1996) were also used.
(JNEB 34:26-37, 2002)
INTRODUCTION
Subjects/Settings: 3100 female and male adults who had participated in the Virginia EFNEP during 1996.
The Expanded Food and Nutrition Education Program
(EFNEP) is a federally funded program administered through
Cooperative Extension1 and is designed to assist limitedresource homemakers and other family members to acquire
the knowledge, skills, attitudes, and practices necessary for a
sound diet, with the long-term goal of improved health and
disease prevention.2 Each year, approximately 6000 limitedresource families in Virginia are enrolled in EFNEP.
Entry and exit assessment of food-related behaviors and
dietary change has been emphasized in the program since
its inception in 1969. In 1993, the computerized EFNEP
Evaluation and Reporting System,Version 3 (ERS3),3 was
implemented nationwide to assess impacts with individual
participants (ie, homemakers) and the total program. It was
upgraded to a Windows version (ERS4) in 1998. With
ERS, dietary intakes of participants are compared with the
Food Guide Pyramid, Dietary Guidelines for Americans,
and the Recommended Dietary Allowances for key nutrients. Behavior changes are compared with recommendations on food resource management, food safety, and nutrition practices.
Throughout its 30-year history, EFNEP has been evaluated for efficacy of program methodology, content, and
Intervention: Prior participation in 6 to 12 food/nutrition
education lessons with subsequent graduation from EFNEP.
Main Outcome Measures: Cost-benefit ratios for EFNEP, based
on original assumptions and subsequent sensitivity analyses.
Statistical Analysis: Program implementation costs were
compiled and compared with monetized benefits of disease prevention to produce benefit-to-cost ratios. Excel and SPSS computer programs were used to compute cost-benefit ratios based
on standard procedures used in the field of economics.
Results: The initial benefit-to-cost ratio was $10.64/$1.00,
with subsequent sensitivity analyses producing ratios ranging
from $2.66/1.00 to $17.04/1.00.
...................................................
This study was funded with a special grant from the Cooperative State Research Education and Extension Service, USDA.
Research was conducted at Virginia Polytechnic Institute and State University.
Address for correspondence: Ruby H. Cox, PhD, RD, 101 Wallace Annex,Virginia
Polytechnic Institute and State University (0228), Blacksburg,VA 24061; Tel: (540)
231-7156; Fax: (540) 231-7576; E-mail: rubycox@vt.edu.
©2002 SOCIETY FOR NUTRITION EDUCATION
26
Journal of Nutrition Education and Behavior Volume 34 Number 1
assessment of diet-related change (the food practice checklist and the 24-hour food recall) and for accomplishment of
positive food-related behaviors.4–9 However, the economic
efficiency of the program was essentially undocumented
prior to the current study. Cost-benefit analysis (CBA) and
cost-effective analysis (CEA) are two popular methods for
evaluating the economic efficiency of intervention programs.10,11 Cost-effective analysis relates program costs in dollars to the amount of outcome achieved, expressed in natural
units such as pounds of weight loss. In CBA, the impacts of
a program are also expressed in dollars and compared in a
ratio with program costs, providing a clear comparison of
benefits and costs. It was the belief of the national EFNEP
program leader and the researchers that the results of a CBA
would be the most effective means of communicating the
value of EFNEP to federal legislators in efforts to gain support for increased funding (Wells Willis, National EFNEP
Leader, personal communication, 1996).
In 1996,Virginia Cooperative Extension was awarded a
grant from the Cooperative State, Research, Education, and
Extension Service, United States Department of Agriculture
(CSREES, USDA), specifically to conduct a CBA of EFNEP,
with methods possibly being adaptable to other nutrition
education programs. Early on, the researchers and the
national EFNEP leader made a decision to base the CBA on
health benefits potentially resulting from EFNEP. Chronic
diseases and health conditions cost society an estimated $250
billion each year in medical charges and lost productivity.The
extent to which these costs might be reduced by healthy eating patterns cannot be calculated precisely, but it has been
estimated that a proper diet might forestall at least 20% of the
annual deaths from heart disease, cancer, stroke, and diabetes.12 The authors of Healthy People 2000: National Health
Promotion and Disease Prevention Objectives13 attributed 50% of
chronic disease mortality to changeable lifestyle factors, such
as diet.
In a CBA, benefits of a program can be classified as direct
and indirect.10,11 The direct benefits of a health-related program may be characterized as costs avoided due to program
results, such as the direct economic cost of diseases avoided
or delayed as a result of positive changes made by participants.
Indirect benefits might be the monetary benefits accruing to
society due to increased productivity of workers who have
improved health, longer lifespans, and a reduction in lost
work time. Direct and indirect benefits that can be easily
monetized are designated as tangible benefits and those that
cannot be easily monetized are labeled as intangible.10,11 In
EFNEP, intangible benefits include improved employability,
self-esteem, and quality of life. Although intangible benefits
need to be examined in CBA where feasible, they are difficult to measure and are not assessed through ERS3.Thus, the
value of intangible benefits was not included in the current
EFNEP CBA.
Costs of a health program also include those that are direct
and indirect.10,11 Direct costs are the actual expenditures for
resources used in program implementation, such as salaries,
January • February 2002
27
equipment, travel, and materials. Indirect costs include unintended expenditures such as value of time lost from work by
participants, the cost of pain and discomfort that participants
suffer, and undesirable expenditures or wealth redistribution
resulting from the program. Indirect costs were not included
in this study.
The purpose of the present cost-benefit study was to evaluate the economic efficiency of the Virginia EFNEP by comparing its monetized health benefits with program implementation costs during 1 year.The perspective of the study
was that of program sponsors, including federal leaders and
legislators who determine funding and direction of the
program.
METHODS
Early on, we made a decision to compute the monetary benefits of EFNEP based on future savings in health care costs
accrued by the potential avoidance or delay of diet-related
chronic diseases and conditions among homemakers who
adopt recommended food-related behaviors and food/nutrient intakes. We used only demographic, dietary, and behavioral data previously collected with ERS3 on 1996 EFNEP
homemakers as there was a desire to know if a CBA procedure was feasible using existing EFNEP data collected
through the ERS. Furthermore, low-income families such as
those in EFNEP tend to be transitory and difficult to locate
after exiting the program, and collection of additional data
would have been costly and time consuming. Only those
homemakers who had graduated were included in the final
analysis, as the methodology necessitated the use of both
entry and exit data.There were 3100 graduated homemakers in 1996 who made up the study sample.
In the first phase of the study, we identified behaviors
taught in EFNEP that might contribute to delay or avoidance of diet-related chronic diseases and conditions that are
believed to be most prevalent among the low-income population (colorectal cancer, heart disease, stroke, hypertension,
osteoporosis, type 2 diabetes, obesity, foodborne illness, commonly occurring infant diseases, and low birthweight
infants).13–28 The behaviors were identified through a review
of the core curriculum of Virginia, the Eating Right Is Basic
Series, 3rd edition.14 Although this series is not used in all 50
states and US territories as the core EFNEP curriculum, the
topics covered are similar in other states due to the existence
of a common set of national program objectives.2 From all
of the behaviors taught in EFNEP, we selected a preliminary
list of those that could be matched with dietary risks for certain chronic diseases and conditions, based on evidence
gleaned from a review of scientific literature.15–29 This list was
posted on a Website, and EFNEP leaders across the nation
were invited to suggest additions and changes. A few suggestions were received and were incorporated into the final
list. Based on this final list of EFNEP behaviors, we identified those that had been assessed by ERS3 and for which we
28
Rajgopal et al/COST-BENEFIT ANALYSIS OF EFNEP
had existing 1996 data files. Identified behaviors and diseases/conditions, for which scientific literature indicates a
preventive role, are shown in Table 1.12,13,22,25,27,29–31
Another step was to clearly link the identified disease prevention behaviors with data collected at entry and exit on
each of the 3100 graduated homemakers. Data on them had
been collected using the EFNEP family record, which
included demographics, a 24-hour food recall, and a 14-item
food practice checklist (FPC). These records had been previously entered into the ERS3 computer program and analyzed for servings of the Food Guide Pyramid,32 intake of
selected nutrients (energy, fat, carbohydrate, protein, fiber,
iron, calcium, and vitamins A, C, and B6), and desired
responses on the FPC. Results of the FPC and food recall
analysis were stored in dBase III format and were easily
imported into the statistical analysis program. Prevention criteria were established for each of the selected diseases for
food/nutrient intakes and food-related behaviors, based on
the 1989 Recommended Dietary Allowances,33 the 1995
Dietary Guidelines for Americans,34 and recommendations
found in scientific literature.13,15–27 These criteria were labeled
as optimal nutrition behaviors (ONBs), as shown in Table 1.
The content of FPC items 3 to 8, for which data are included
as part of the ONBs, is shown at the bottom of Table 1. To
meet the ONB standard, the homemaker had to be practicing the desirable behavior “most of the time” or “almost
always.” An important consideration is whether the
food/nutrient intakes and food behavior data collected on
the homemakers were reliable.When the ERS program was
implemented in Virginia in 1993-1994, a great deal of training was conducted with EFNEP field staff regarding the collection of data for the family record, and this was believed to
have increased the probability that 1996 dietary and behavioral data were collected in an accurate manner.
Important data compiled from the literature search
included the treatment costs of the diseases/conditions
included in this study.These were computed as the national
average cost per patient per year and are listed in Table 1.
They ranged from a low of $348 for hypertension to $30,000
for initial and first-year medical care of a low birthweight
infant.The costs used in our CBA were those that reflected
the most common course of treatment for a disease, with
conservative estimates usually being used. For heart disease,
we used the more conservative cost for nonsurgical treatment
of $3676. In the case of obesity, only costs associated with
weight loss clinics and/or weight loss supplements were
used since these were viewed as the more common treatments. Also, the disease treatment costs actually used in the
CBA formula had been adjusted to 1996 values, using standard procedures to adjust for inflation.11
In the second phase of the study, the Statistical Package for
the Social Sciences,Version 7.5 (SPSS 7.5)35 was used to select
participants from among the 3100 graduates who met the
selected criteria for the ONB (see Table 1). This was done
individually for each disease/condition and was applied separately to entry and exit data. For example, to be designated
as avoiding heart disease, a homemaker had to meet all of the
following criteria: score 4 or higher on items 6, 7, and 8 of
the FPC and consume 65 g or less of fat, five servings or more
of vegetables and fruits combined, and 20 g or more of fiber.
Furthermore, if homemakers already met the criteria at
entry, their data were not included in the benefit calculations
for that disease.This was done to increase the likelihood that
participants had acquired the ONB as a result of EFNEP.
Also, if critical data related to an ONB were missing, a homemaker would not be selected as meeting all of the criteria for
that disease and thus would be eliminated from the benefit
calculation. The number of homemakers meeting the prevention criteria for a particular disease/condition, at exit but
not at entry, was converted to a percentage of the sample of
3100 homemakers.
In the third phase of the study, the data gleaned from the
previous procedures were incorporated into a CBA formula.
Various principles and procedures from the field of economics10,11,36–38 were used to monetize the benefits and to
determine the costs of implementing EFNEP in Virginia in
1996.These two data sets, monetized direct and indirect benefits and direct costs, were used to generate a benefit/cost
ratio.The procedures used in this phase are fully described in
the Virginia EFNEP CBA final report,36 with only a brief
summary being provided here.
Method of Monetizing Direct, Tangible Benefits of
EFNEP The direct tangible benefits of EFNEP were characterized as dollars saved on health care costs by the potential delay/avoidance of chronic diseases and conditions as a
result of participants adopting ONBs. These benefits were
valued in dollars by their nonbiased market prices (ie, the cost
of medical care for a disease or condition). Direct tangible
benefits were equal to the 1996 “present value” of the treatment dollars saved.
To compute the present value, it was necessary to discount
future benefits (ie, costs avoided for specific time periods) to
estimate what those benefits would be worth in 1996, the
base year of this study.The rationale for discounting is that a
given sum is worth more today than an equal sum at some
future date because the money can be profitably invested in
the interval between today and the future.39 For example, the
present value or “today’s value” of $1.00 to be received at a
future time, when discounted at a 10% rate, is $.90.A rate of
5% was used in the current study as this is the rate used in
most CEAs of health care interventions.
The diseases/conditions were separated into three categories,Type A, B, and C, based on the researchers’ judgments
of the usual progression of the diseases13,25,27,40 and whether
it was reasonable to expect the disease/condition to be prevented or just to be delayed as a result of the adoption of the
diet-related behaviors taught in EFNEP.Another consideration was whether the disease often results in death in the
short term or is not immediately life threatening but requires
treatment for many years.Type A diseases (colorectal cancer,
Journal of Nutrition Education and Behavior Volume 34 Number 1
Table 1.
January • February 2002
29
Diet-Related Chronic Diseases/Conditions and Treatment Costs, Behaviors/Practices Taught in EFNEP That Reduce Risk of These
Diseases/Conditions, and Criteria for Optimal Nutritional Behaviors
Behaviors and Dietary Intake Assessed in EFNEP
and ONB Criteria Used in Selecting Homemakers
Designated as Receiving Disease Prevention Benefit
Disease/Health Condition
and Yearly Treatment Cost
FPC Score
Dietary: Optimal
FPC
for Optimal
Food/Nutrient
Associated Nutritional Behaviors Taught in EFNEP
Item No.
Behavior
Levels
Bypass surgery = $30 000
Decreased intake of sodium/salt
6*
≥ 4†
Other treatments = $3676
Prepare food with less fat, less salt
(for 1997)30
Decreased fat intake
per Patient Reported in
Scientific Literature
Heart disease
7‡
≥ 4†
≥5 servings
Fiber ≥ 20 g
Increased intake of complex carbohydrates, fiber,
fruits, vegetables
Fat ≤ 65 g
Vegetables + fruits
8§
≥ 4†
6*
≥ 4†
Vegetables + fruits
7‡
≥ 4†
Calcium ≥ 800 mgıı
3¶
≥ 4†
Fat ≤ 65 g
8§
≥ 4†
Using food labels to select food
Meal planning around FGP and DGs
Reduce/control weight
Increased physical activity
Stroke and hypertension
Treatment cost
Stroke: $22 000
Prepare/serve food with less salt
13
≥5 servings
Using food labels to select food
Hypertension: $34812
(for 1995)
Meal planning around DGs
Reduce/control weight
Increased physical activity
Colorectal cancer
Treatment cost: $28 000
(for 1995)
13
Increased intake of fiber, complex carbohydrates,
vegetables and fruits, vitamins A and C,
and calcium
Vegetables + fruits
≥5 servings
Fiber ≥ 20 gıı
Decreased fat intake
Meal planning around FGP and DGs
Food selection and preparation (to reduce fat and
carcinogens)
Osteoporosis
$11 582 per patient
(for 1994)
Increased intake of milk products and calcium-rich
22
3¶
≥ 4†
foods
Milk group ≥2
servings
Calcium ≥ 800 mgıı
Food selection around FGP
Increased physical activity
Foodborne illness
Treatment cost: $942
(for 1995)
27
Food safety techniques and kitchen sanitation
4#
≤ 2**
5††
≤ 2**
3¶
≥ 4†
Not applicable
Proper food storage
Use of recommended food preservation methods
Safe thawing practices
Safe cooking and handling of meat and eggs
Safety methods for carried meals (lunch, picnics, etc)
Obesity
Treatment costs: $625
Based on 1996 cost
25
Increase intake of fiber, complex carbohydrate, fruits
and vegetables
Fat ≤ 65 g
Vegetables + fruits
8§
≥ 4†
≥5 servings
(this cost includes only the
Decreased caloric intake
estimated funds spent by
Increased physical activity
Fiber ≥ 20 g
patients in attending weight
Decreased intake of fats and sweets group
Energy ≤ 2200 kcal‡‡
control programs/clinics or
Food preparation to reduce fat and calories
purchasing special products
Using food labels to select food
for weight reduction)
Use of other sound weight control methods
(Continued)
30
Rajgopal et al/COST-BENEFIT ANALYSIS OF EFNEP
Table 1.
Continued
Behaviors and Dietary Intake Assessed in EFNEP
and ONB Criteria Used in Selecting Homemakers
Designated as Receiving Disease Prevention Benefit
Disease/Health Condition
and Yearly Treatment Cost
FPC Score
Dietary: Optimal
FPC
for Optimal
Food/Nutrient
Associated Nutritional Behaviors Taught in EFNEP
Item No.
Behavior
Levels
Increased intake of fiber, vegetables, and fruits
3¶
≥ 4†
Energy ≤ 2200 kcal‡‡
8§
≥ 4†
Carbohydrate ≥250 g
None
NA
“True” response for
per Patient Reported in
Scientific Literature
Type 2 diabetes
Treatment cost: $6182
(for 1996)
25
Fiber ≥ 20 g
Decreased intake of fats and sweets group
Weight control increased physical activity
Plan foods around FGP and DGs (based on
instructions of physician/registered dietitian)
Using food labels to select food
Common infant diseases
Treatment cost: $1435
Adoption of breast-feeding
(for 1993)31
Use of proper breast-feeding techniques
breast-feeding
Healthy eating in pregnancy
Type C condition
Low birthweight infants
Treatment cost: $30 000
(for 1992)29
Planning meals around FGP and other dietary
recommendations for pregnancy
None
NA
“True” response for
pregnant
Energy ≥ 2100 kcal
Optimum use of WIC foods
Proper infant feeding/breast-feeding
Includes cost of neonatal
intensive care and other
first-year costs
Following other recommendations in pregnancy
and infancy
Appropriate weight gain
*Prepares or eats foods without adding salt; †for FPC items 3 and 6 to 8, has the desired response of “most of the time = 4” or “almost always =
5”; ‡reads food labels to select foods with less salt and sodium; §reads food labels to select foods with less fat; ııbased on the 1989 RDA for calcium
for females, aged 11 to 51+ years, as optimal intakes had not been published when analysis was done; ¶when deciding what to eat or to feed family, thinks about healthy food choices; #lets meat and dairy foods sit out of refrigerator for 2 hours or more; **for items 4 and 5, has the desired response
of “do not do = 1” or “seldom = 2”; ††thaws food by leaving it on counter or table; ‡‡based on the 1989 RDA for energy for females, aged 15 to 50 years.
EFNEP indicates Expanded Food and Nutrition Education Program; ONB, optimal nutrition behavior; FPC, food practice checklist; FGP, Food Guide
Pyramid; DGs, Dietary Guidelines for Americans; NA, not available; WIC, Special Supplemental Nutrition Program for Women, Infants and Children.
cardiovascular disease, stroke, and hypertension) are those we
considered more difficult to prevent and that can be immediately life threatening. Although mild hypertension is not
immediately life threatening, severe hypertension may result
in medical problems (stroke, cardiovascular disease, congestive heart failure, peripheral vascular diseases, aneurysms, and
kidney disease)40 that are life threatening. Although including hypertension as a separate condition represents some
overlap with stroke and cardiovascular disease, we felt that its
contribution to other diseases40,41 warranted separate treatment in the analysis.
The approach in this study was to assume that Type A diseases/conditions could be delayed (but not avoided) by
adopting the nutrition behaviors taught in EFNEP. This
delay would result in a dollar benefit based on foregoing the
treatment cost of the disease for a certain number of years.
However, the value of that savings had to be discounted to
obtain the 1996 “present value,” as discussed above. The
direct tangible benefit is the discounted value that would be
obtained by delaying treatment from time 1 to time 2, with
time 1 being the average age of onset of the disease and time
2 being the delayed age at which the disease might occur. For
example, the age at which heart disease normally occurs is
55 years, whereas we assumed that it could be delayed to age
60. It is important to note that using the average age when
a disease might occur as time 1, then discounting over the
subsequent 5 years, actually reduced the “present values” for
Type A diseases to amounts below the 1996 treatment costs
in Table 2.
Type B included those diseases viewed as non-life threatening but that would necessitate treatment costs from the
time of onset throughout life or for some designated period
Journal of Nutrition Education and Behavior Volume 34 Number 1
of time.These included osteoporosis, type 2 diabetes, obesity,
common infant diseases (eg, otitis media, respiratory infections, viral infections, gastroenteritis), and foodborne illnesses. Our approach was to assume that adoption of a set of
diet/food-related practices could result in avoidance of the
diseases/conditions. This avoidance would result in a dollar
benefit based on foregoing the treatment costs for those diseases for the remainder of life.Thus, the direct tangible benefits of foregoing treatment costs are the “present value” of
the treatment cost calculated from the average disease-onset
age through the average life expectancy or for an appropriate period of time (eg, for common infant diseases, the
period was 1 year). The average life expectancy of 78 years
for American women42 was used in calculations since most
of the participants were women. Since obesity is a risk factor in diabetes and heart disease, any costs related to those diseases were not included in determining the treatment cost of
obesity.
The only Type C condition was low birth weight for
infants. This condition differed from Type A and B diseases/conditions because we used only the average treatment
cost incurred at the infant’s birth and during the first year of
life.29 Although low birth weight can result in increased
health care cost in subsequent years, we based our analysis
only on the avoidance of early treatment costs, adjusted to
1996 values.This value was calculated on those participants
indicating that they were pregnant. The cost was not discounted as it would have occurred within a year of graduation from the program.
With the aid of Microsoft Excel,43 a CBA formula was
used to derive the tangible benefits of EFNEP per disease/condition.The formula was [A] × [B] × [C] × [D] × [E]
= F. The components of this formula are as follows (see Table
2 for clarity):
[A] Annual number of EFNEP graduates having entry and
exit data, which was 3100 in 1996;
[B] Disease/condition incidence rate for the population (as
reported in the literature15–29), with the disease rates for
the low-income US population being used if available;
otherwise, incidence rates for the general population
were used;
[C] Portion of the disease/condition believed to be related
to diet, which was the estimated percentage of those
who would normally get the disease but who might
avoid or delay its onset by adopting recommended
nutrition behaviors15–29;
[D] Percentage of graduates with ONB related to avoiding
or delaying the disease/condition;
[E] Present value of those monetary benefits;
[F] Total benefit for all of the diseases/conditions, based on
the potential delay or avoidance of disease treatment
costs among the 3100 program graduates in 1996.
Variables A through D in the formula were used to derive
the number and percentage of participants who would accrue
the benefit (ie, avoid or delay onset of the disease/condition).
January • February 2002
31
The percentage of EFNEP graduates with ONB was those
for whom certain food/nutrient intakes and food behaviors
met all predetermined criteria at exit but not at program
entry, as determined with the SPSS procedure.
Monetizing Indirect Tangible Benefits of EFNEP
Data on indirect tangible benefits accruing to 1996 EFNEP
graduates were calculated as a part of the overall study, with
the process being described in the final study report.36 These
data were based on the assumption that productivity or personal earnings are jeopardized if a person becomes ill and
cannot work. Avoiding or delaying the loss of productivity
from morbidity (ie, earnings foregone from lost workdays)
becomes a monetary benefit as it increases earning potential.44
Assumptions on Which Calculations of Benefits Were
Based We used three critical assumptions in deriving the
benefits: (1) benefits for Type A diseases/conditions were
based on delaying the onset of a disease/condition for a minimum of 5 years, whereas benefits for Type B diseases were
based on avoiding the disease/condition for the duration of
life; (2) monetized benefits would be calculated only for
EFNEP homemakers (not for other family members) practicing ONB at exit from the program; although it was
believed that benefits extended to other family members,
there was no way to calculate this from ERS data; (3) selected
EFNEP graduates practicing ONB at exit would continue to
practice the positive nutrition behaviors for the remainder of
their lives. Results of studies within the past two decades
indicate that positive nutrition behaviors do not regress
when EFNEP graduates leave the program.6–8,45,46 To ensure
that results could be attributed to EFNEP, graduates were not
included in the final calculation of EFNEP benefits if their
behaviors met the selected criteria at program entry.
For the Type C condition of low birth weight, maternal
age, high parity, poor reproductive history, low socioeconomic status, and poor maternal nutrition are among the
dominant risk factors.47 The incidence rate of low birth
weight in the US is 7.3%.28 No specific figure is reported in
the literature for the portion of low birthweight infants
attributable to diet, but we used 100% since birth weight is
strongly associated with adequate weight gain in pregnancy
and other nutrition-related factors.47 The average onset of
this condition is 1 year as participants had to be pregnant
while in EFNEP to be included in the analysis.The average
cost of neonatal intensive care and other care during the first
year of life for one low birthweight infant was reported as
averaging $30 000.29
Costs of Implementing EFNEP in Virginia The direct,
tangible costs of conducting the EFNEP were identified as
salaries, fringe benefits, office space, utilities, equipment, educational and office supplies, special training expenses, and
travel costs. Cost data were obtained primarily from university accounting reports showing expenditures from state and
1537
Common infant diseases
35 406
37.0#
55ıı
At birth
23
7.3
100.0#
1
≤1
1
14.5#
38ıı
40
23
2.8
84 (2.7)
59 (1.9)
87 (2.8)
59 (1.9)
1664 (53.7)
885 (28.5)
34 (1.1)
290 (9.4)
59 (1.9)
290 (9.4)
6.11
10.90
86.80
3.84
46.61
247.38
2.77
49.04
3.09
35 406
11 687
1537
45 898
18 867
65 469
692
698
16 425
13 144
$
Benefits‡
4.95
Benefit,§
Accruing
%
with ONB,†
Present
Value of
Graduates
No. of
[E]*
Graduates
No. of
[D]*
17 880 626
216 334
127 343
133 412
176 397
879 413
16 195 687
1914
34 225
50 789
65 112
$
Benefit,ıı
Direct
Total
[F]
EFNEP indicates Expanded Food and Nutrition Education Program; NA, not available.
These incidence rates are specifically for the low-income population, whereas all others are for the general adult population.
From age of onset to 78 years of age, which was the 1996 life span for women.
ıı
#
Total benefit of delaying/preventing the disease for the homemakers who adopted recommended nutrition behaviors in EFNEP.
§
This was calculated on the assumption that at least one homemaker would get a foodborne illness each year for 55 years, in the absence of EFNEP.
Calculated from preceding data in this table and using 1996 cost of treating the disease or condition.
‡
¶
Graduates accruing benefits constitute the number of cases used in calculating the monetary benefit for each disease.
†
than one disease category.
*ONB indicates optimal nutrition behaviors. A total number of participants with ONB for all diseases combined was not calculated as there may be overlap with some participants falling in more
NA
50.0
NA
45.0
100
NA
26.0
31.2#
28.0
45.0
37.4#
NA
35.0
1.7
%
Portion,
Related
Diet-
[C]*
15.0
55ıı
5
5
5
5
%
Population,
55¶
45
55
30
36
45
y
Onset,
Rate in
Disease
[B]*
*This component incorporated directly into cost-benefit analysis formula: [A] × [B] × [C] × [D] × [E] = [F].
Total direct tangible benefits
Low birthweight infant
Type C:
625
6182
Type 2 diabetes
Obesity
1009
Foodborne illness
Osteoporosis
11 828
3517
Heart disease
Type B
364
33 046
Hypertension
23 025
Colorectal cancer
y
Onset,
$
Cost/Person,
Stroke
Type A
Disease/Condition
Age of
from Average
Age of
Disease
Adjusted
Treatment
Average
Treatment
1996
Data Used in the Cost-Benefit Analysis Formula for Calculating Direct Tangible Benefits for Type A, B, and C Diseases/Conditions (N = 3100 Graduated EFNEP Homemakers Used as
Formula Component [A])*
Table 2.
32
Rajgopal et al/COST-BENEFIT ANALYSIS OF EFNEP
Journal of Nutrition Education and Behavior Volume 34 Number 1
federal funds. A questionnaire, completed by local Extension
staff, provided information on the dollar value of local
resources used in support of EFNEP (eg, value of office space,
utilities, equipment, and telephone service). Intangible costs
were not included as these data were not available.
Final Benefit/Cost Ratios and Sensitivity Analyses
The value of tangible direct and indirect benefits was added
and compared with the direct total cost to provide a ratio.To
address uncertainties in the CBA due to missing disease incidence values and assumptions made in the initial analysis, several sensitivity analyses were conducted with the method
more fully described elsewhere.10,36 However, this procedure
used the same CBA formula as was used in other analyses,
with adjustments being made in disease incidence rates, portion of diseases affected by diet, and number of graduates
achieving ONB.
RESULTS
Original data collected from the literature search, certain
variables calculated from that original data, and all components used in calculating the total benefit side of the CBA
ratio are listed in Table 2.The 1996 adjusted cost of treatment
for each disease/condition is listed in the second column and
ranged from $364 (hypertension) to $33 046 (colorectal cancers) for Type A diseases and from $625 (obesity) to $11 828
(osteoporosis) for Type B diseases.The Type C condition of
low birth weight had an adjusted 1996 cost of $35 406. Note
that these costs are higher than those reported in the literature due to adjustments for inflation, except for the cost of
heart disease being lower due to reducing the 1997 figure
($3675) to the estimated 1996 value of $3517.
The average age of disease onset and years of survival after
diagnosis are listed in the third and fourth columns of Table
2 and were used in determining the total cost of disease for
one person for a span of time (ie, 5 years for Type A and the
remainder of life for Type B diseases). Incidence rates of the
disease in the population are reported in the fifth column,
with the lowest rates being for stroke (1.7%), foodborne illness (2.8%), and low birthweight infants (7.3%).The highest
incidence rate was for common infant diseases (100%) since
nearly all infants have at least one episode of these diseases.
Other diseases with high incidence rates for adults are hypertension (37.4%), obesity (37%), heart disease (31.2%), and
osteoporosis (28%). Specific rates for the low-income population were available only for hypertension, type 2 diabetes,
common infant diseases, and obesity. Diseases for which estimates were available on the portion of the disease related to
diet are reported in the sixth column.Values ranged from 26%
for heart disease to 100% for foodborne illness; however, data
were not available for stroke, osteoporosis, and common
infant diseases. Since there were no percentages to enter into
the formula for these diseases, the portion was treated as if it
were 100%. However, sensitivity analysis was done for osteo-
January • February 2002
33
porosis, in which 50% was used as the portion related to diet
(discussed below).
Numbers and percentages of graduates practicing ONB
for the diseases/conditions are listed in the seventh column
of Table 2.The lowest values were 1.1% (34 individuals) for
heart disease and 1.9% (59 individuals) each for colorectal
cancer, type 2 diabetes, and obesity. The highest values
obtained included 53.7% (1664 individuals) for foodborne
illness and 28.5% (885 individuals) for osteoporosis. The
eighth column lists the number of cases ultimately used in
calculating the monetary benefits once the numbers of individuals achieving ONB were adjusted downward to account
for the fact that only a portion of the population would be
expected to acquire the disease and only a portion of disease
cases can be attributable to diet.
The ninth column of Table 2 presents the “present value”
for the estimated benefits accrued for each disease, based on
the adjusted 1996 treatment cost for one person, summed
over the years for which the disease would be delayed (5
years) or avoided (remainder of life).These ranged from very
high values for osteoporosis ($65 469), type 2 diabetes
($45 898), and low birthweight infants ($35 406) to low values for heart disease ($692), hypertension ($698), and common infant diseases ($1537).
The last column of Table 2 lists the total direct benefits for
each disease and for all diseases combined. By assuming a
delay of 5 years for Type A diseases/conditions, the estimated
total direct tangible benefits were $65 112 for stroke, $50 789
for colorectal cancer, $34 225 for hypertension, and $1914 for
nonsurgical treatment of heart disease.
The calculated benefits for avoidance of Type B disease/conditions for the remainder of life were $16 195 687
for osteoporosis, $879 413 for foodborne illness, $176 397 for
type 2 diabetes, $133 412 for common infant diseases, and
$127 343 for obesity.Avoidance of the Type C condition, low
birth weight in infants, resulted in a calculated direct tangible benefit of $216 334. The total direct benefit from the
avoidance or delay of all of the diseases and conditions was
$17 880 626.
Values for indirect tangible benefits resulting from avoidance or delay of the above diseases were obtained by a
method described in the full report of the study.36 The values included $879 for type 2 diabetes, $1921 for heart disease, $10 318 for stroke, $21 272 for obesity, $74 569 for foodborne illness, and $234 395 for hypertension, with a total
indirect tangible benefit of $343 354.
Table 3 lists the direct tangible costs of implementing the
1996 Adult EFNEP in the state.These included salaries and
fringe benefits ($1 202 973), office space ($35 568), utilities
($90 480), equipment ($2676), supplies/training ($69 582),
and staff travel ($62 893). Because the program is delivered
primarily in small groups in participants’ homes and at times
convenient to them, indirect costs to participants were considered minimal and were not included in calculations. A
marginal excess burden of taxation (17% = $248 909) was
also included in the direct costs as this is an assumed cost
34
Rajgopal et al/COST-BENEFIT ANALYSIS OF EFNEP
when federal dollars are involved.48 The total cost of conducting the Virginia Adult EFNEP for 1996 for all participants was $1 713 081.
Total benefits (direct and indirect intangible) were
summed and incorporated into a ratio with the total cost,
yielding a benefit/cost ratio of $10.64/$1.00. Sensitivity
analyses, to address uncertainties in initial assumptions and
lack of certain disease incidence data, resulted in benefit/cost
ratios ranging from $2.66/$1.00 to $17.04/$1.00.When the
number of graduates to achieve the optimal behaviors was
reduced by 75%, a ratio of $2.66/$1.00 was obtained, and
when the number was reduced by 50%, a $5.32/$1.00 ratio
was obtained.When 50% was assumed to be the portion of
osteoporosis due to dietary factors, a ratio of $5.91/$1.00 was
obtained. When a ratio was calculated using only estimated
disease incidence rates for the low-income population, a benefit/cost ratio of $17.04/$1.00 was obtained. For this last calculation, we used estimated values for the low-income population that were higher than those of the general population.
DISCUSSION
The initial benefit/cost ratio of $10.64/$1.00 indicates that,
for every dollar spent on the program, the potential exists that
over 10 dollars may be saved in future health care cost.This
represents a significant return on investment for the Virginia
EFNEP. However, the most promising finding of this study
is that it is feasible to conduct a CBA on the results of a nutrition education program. Economic evaluations, especially
CBA, reported for health care programs are few and those
conducted with nutrition education are even fewer.
To ensure the credibility of the current study results, stringent criteria were applied in selecting the EFNEP participants who would accrue the benefits due to having adopted
the ONBs. In spite of this, a high benefit/cost ratio was
obtained because a significant proportion of the EFNEP
graduates had adopted the ONBs.There is a possibility that
Table 3.
influences outside of EFNEP contributed to the positive
behavior changes, but this possibility was minimized by
excluding participants from the benefit calculation for a disease if they already met the ONB criteria for that disease at
entry.The achievement of stringent criteria by the graduates
also indicates that the Virginia EFNEP is successful in achieving program objectives. In a climate of scarce health care
resources, the results of this study indicate that the allocation
of federal funds to the Virginia EFNEP is justified. If other
states’ EFNEP programs show a similar positive benefit, the
nationwide appropriation represents a very good investment. Economic benefits from the delay or avoidance of disease, due to adoption of recommended dietary habits and
food-related skills, could be used as a strong incentive for
families to enroll in the program and for legislators to
increase funding for EFNEP.
The USDA spent $295 million from tax dollars on nutrition education programs in 1994.49 To ensure that the public is receiving maximum benefit from tax dollars supporting these programs, it is important to objectively assess their
effectiveness and impact in comparison to cost of implementation.When making future decisions on allocation of its
resources, it seems reasonable that the federal government
would allocate those resources to the most deserving programs in terms of economic and process efficiency.50
Use of Sensitivity Analysis Useful interpretation of
CBA results necessitates that uncertainties in the analysis be
addressed. Program evaluations indicating a range of estimates
from sensitivity analyses are the most useful because they provide comprehensive information on which decision makers
can base their interpretations.10,44 One variable in the current
study that lends uncertainty to results was the lack of incidence rates for some diseases for the low-income population.
Incidence rates for 5 of the 10 diseases/conditions (stroke,
colorectal cancer, osteoporosis, foodborne illness, and low
birth weight) were for the general population.Thus, a sensitivity analysis was performed to adjust the general population
Direct Costs of Implementing EFNEP in Virginia in Federal Year 1996
Costs
Description
Amount, $
1 202 973
Funding Source
Salaries and benefits
Total funds allocated to paid staff
Office space
Value of office space
35 568
State and local
Federal
Utilities
Cost of electricity, telephone, and water prorated
90 480
State and local
to that used by EFNEP staff
Equipment
Equipment used in all 26 units
Supplies/training
Total funds allocated to all EFNEP units for supplies
2676
Federal
69 582
Federal
62 893
Federal
248 909
Federal
and training
Staff travel
Total funds allocated to EFNEP staff for travel
Marginal excess burden
Marginal excess burden of taxation was 17% of total
direct costs
Total cost
EFNEP indicates Expanded Food and Nutrition Education Program.
1 713 081
Federal, state, and local
Journal of Nutrition Education and Behavior Volume 34 Number 1
incidence rates to be more reflective of the low-income population.The procedure we used increased the incidence rates
for each of these five diseases/conditions by 11 percentage
points, resulting in a higher benefit/cost ratio of
$17.04/$1.00.36 The authors of Healthy People 2000 stated
that “for virtually all chronic diseases leading the Nation’s list
of killers, low income is a special risk factor.”13 This supports
our belief that, had the higher incidence rates of chronic diseases for the low-income population been available, the benefit/cost ratio for the Virginia EFNEP would have been
higher.
On the other hand, the CBA ratio might have been lower
if complete data had been available for the portion of diseases/conditions attributable to diet. Unfortunately, there was
a lack of information on incidence attributable to diet for
stroke, osteoporosis, common infant diseases, and low birth
weight for infants, with the result that they were treated as
being 100% related to diet due to the nature of the CBA formula.The authors recognize that 100% is probably too high
but had no evidence on which to select different percentages
in the initial analysis. A sensitivity analysis was conducted
using 50% as the portion of osteoporosis due to diet, which
reduced the number of participants receiving the osteoporosis benefit to 442 (see Table 2) and resulted in a total
benefit/cost ratio of $5.91/$1.00.
Additional sensitivity analyses were conducted to address
uncertainties in long-term retention of positive dietary behaviors among the 3100 graduates. The resulting benefit/cost
ratio was $5.32/$1.00 when it was assumed that only 50% of
the graduates (1550 individuals) would retain the positive
behaviors over a lifetime.When it was assumed that only 25%
of graduates (775 individuals) would retain the behaviors, a
lower but still positive benefit/cost ratio of $2.66/$1.00 was
obtained.
It was quite apparent that osteoporosis accounted for the
majority of the tangible benefits (89%) from EFNEP.
Although there is strong agreement that dietary factors play
an important role in osteoporosis, researchers have not
offered an estimate of the percentage of osteoporosis cases
that could be prevented by positive dietary changes. Given
this, the calculated tangible benefit from osteoporosis may be
overstated as there was no adjustment made for the incidence
rate related to diet. Hence, we conducted a sensitivity analysis using a 50% incidence rate of osteoporosis related to diet,
but this should be viewed as a very rough estimate.Although
this adjustment lowers the benefit/cost ratio to $5.91/$1.00,
the benefits from osteoporosis still make up 80% of the total
benefits.
Osteoporosis is a condition that has greatly increased in
recent years, especially among US adult females.22 The majority of EFNEP participants are women, potentially having several risk factors for osteoporosis (low intake of calcium and
vitamin D, high intake of phosphorus and sodium, smoking,
and inadequate physical activity).9 However, osteoporosis is
largely preventable for most people with proper diet
throughout life, adequate physical activity, and avoidance of
January • February 2002
35
several other risks, such as smoking, hormonal imbalances,
etc.26,40 One reason for the high dollar benefit contributed by
osteoporosis avoidance is that our data indicate that EFNEP
was very successful in achieving a high level of adoption
(28.5%) of the ONBs believed to reduce the risk of osteoporosis. Since the average age of EFNEP participants is 23
years and the usual age of onset of osteoporosis is 45 years or
older, there is time for EFNEP intervention to positively
impact osteoporosis prevention.Thus, we believe that avoidance of costs for treating osteoporosis is a justifiable and significant benefit of EFNEP.
Since the benefit/cost ratio was calculated only on the
subset of participants who practiced the ONBs, it is reasonable to assume that there would be benefits accruing to participants practicing only some of the positive nutrition
behaviors. Furthermore, results of the current study could
have been greatly enhanced if the EFNEP family record had
captured a wider range of impacts. For instance, information
on the duration and extent of physical activity among participants could increase the monetary benefits related to
avoiding most of the chronic diseases/conditions. Similarly,
perinatal information on pre-pregnancy and pregnancy
weight gain of the mother, birth weight of the neonate, and
duration of breast-feeding could support the criteria for
selection of graduates who accrue the benefits of disease
avoidance.
IMPLICATIONS FOR RESEARCH AND
PRACTICE
Given the many influences that foster unhealthy lifestyles and
the barriers to effective nutrition education targeting lowincome populations, a positive result of any size in a CBA
should be gratifying to program sponsors and leaders. Nutrition education is often only one component of multifaceted
programs that may vary considerably in content, scope, and
duration. This may lead to difficulty in documenting and
comparing the specific results of the nutrition education
component. Measuring behavioral change, evaluating health
outcomes, and determining economic benefits are all complex
and difficult to link to interventions.The greatest value of the
results of this study may be the fact that it is the first time that
economic theories of CBA have been successfully applied to
a nutrition education program of the magnitude of EFNEP.
In fact, there are few reports of CBA being applied to any
nutrition education programs. Insights gained in this study
indicate that it would be feasible for other programs to apply
CBA if they have sound behavioral impact data.
On the other hand, the process revealed that there are several inherent difficulties with the use of CBA in nutrition
education programs. For example, the results of a CBA are
useful only if sound data collection and data storage procedures are already in place.A CBA of EFNEP was possible due
to the well-established assessment procedures of the EFNEP
ERS and the ability of assessment tools to capture behavioral
36
Rajgopal et al/COST-BENEFIT ANALYSIS OF EFNEP
impacts of the program. The decision to use existing ERS
data proved to be sound because the availability of both preand postintervention data made it possible to identify those
graduates practicing ONBs at exit but not at program entry.
Furthermore, the results of this study affirm that data collected through ERS are suitable for application to a cost-benefit framework.
The cost-of-illness approach used in this study made the
problem of assessing benefits more manageable but had its
own complexities. Data on disease incidence rates among the
low-income population and treatment costs for diet-related
diseases were not available for several diseases. Some disease
treatment costs that were available did not appear to reflect
total economic costs of the diseases.Another problem was the
lack of data on the portion of some diseases and conditions
that could be attributed to diet. Further research is needed
to determine disease incidence rates for low-income populations for various chronic diseases, not only for purposes of
conducting CBA but to guide policy in directing chronic disease prevention programs to the most at-risk groups. It is
important that scientists, having extensive knowledge and
research experience with diet-related diseases, provide estimates on the portion of disease incidence that could be
reduced by appropriate dietary and lifestyle modifications.
In conclusion, further research is needed to determine the
true economic benefit of EFNEP in terms of reducing
health care costs with its participants. Based on the fact that
results of the initial analysis and subsequent sensitivity analyses gave positive benefit/cost ratios and only benefits to graduates (but not all participants) were included, it seems reasonable to conclude that funding for EFNEP represents a
very good investment for federal funds.
NOTE
A copy of Applying Cost-Benefit Analysis to Nutrition Education Programs: Focus on the Virginia Expanded Food and Nutrition Education Program—Final Report (1999) may be
obtained by contacting Ruby Cox.
ACKNOWLEDGMENTS
This study was funded with a special grant from the Cooperative State Research Education and Extension Service, USDA.
Special thanks goes to Wells Willis, National Program LeaderEFNEP, CSREES-USDA, for making the funding available
and for assisting in the development of study procedures.
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