Implications of an Economic Evaluation of Projected Health Outcomes in a Community Nutrition Program for Limited-Resource Audiences

Year: 2001

Research Center: Joint Center for Poverty Research, University of Chicago and Northwestern University

Investigator: Kenkel, Donald, Jamie Dollahite, Michelle Scott-Pierce, and C. Scott Thompson

Institution: Division of Nutritional Sciences, Cornell University

Project Contact:
Donald Kenkel, Associate Professor
Cornell University
College of Human Ecology
Department of Policy Analysis and Management
N230 Martha Van Rensselaer Hall
Ithaca, NY 14853-4401
Phone: 607-255-2594
Fax: 607-255-4071


The objective of this research was to apply and extend economic evaluation methods—cost effectiveness analysis (CEA) and cost benefit analysis (CBA)—to the Expanded Food and Nutrition Education Program (EFNEP) in New York State. EFNEP is a national nutrition education program, delivered through the Cooperative State Research, Education, and Extension Service in all 50 States and 6 territories with funding from the U.S. Department of Agriculture. It is designed to improve the diet and nutritional well-being of low-income families and to contribute to their personal development. The authors adopted a broad societal perspective, consistent with the goal that the economic evaluation provide more general guidance on the allocation of resources among EFNEP, other food and nutrition programs, and other uses. The evaluation also has important implications for allocations of resources and program management within a State.

Previous research reported CBAs for the Virginia, Iowa, and Tennessee EFNEPs. The Tennessee CBA measured actual savings in food expenditures realized by participants and reported an average savings over 5 years of $2.48 in direct food costs for every dollar spent on EFNEP. The Virginia and Iowa studies assessed projected health benefits of between $10 and $11 for every dollar spent. Neither study included estimates of CEAs or of society’s willingness to pay for improved health.

In fiscal year 2000, when data were collected for the present study, 5,730 adult participants graduated from the New York EFNEP. For the cost-benefit analysis, the study included all costs of the adult program (Federal, State, and local dollars). The authors collected information from graduates of EFNEP nutrition education classes on nutrition and food safety practices before and after attending the classes. Health benefits, estimated from the outcome data, were monetized using secondary data sources. The method used in Virginia was replicated, and revisions were made for comparison. Incidence rates for the diseases assessed were updated from those used in the previous studies. Lifetime risk (cumulative incidence) was used for chronic conditions. Criteria for success in dietary change, as well as rates for diet-attributable risk—particularly for osteoporosis, stroke, and commonly occurring infant diseases—were changed to be more consistent with current understanding of the effect of diet on health outcomes. The effectiveness of EFNEP in reducing future health care costs and society’s willingness to pay for the projected improvements in morbidity and mortality were estimated. The CEA used quality-adjusted life-years (QALYs) to measure people’s utility levels and preferences over different health states, expressing these in a common metric.

The estimated benefit-to-cost ratio for New York’s adult EFNEP was $3.17 to $1.00. Cost per graduate was higher in New York ($849) than in Virginia ($553) or Iowa ($710). In addition, a smaller percentage of participants had changed to optimal nutrition behaviors in New York. Therefore, the benefit-to-cost ratio in New York was only about one third of those reported for Virginia and Iowa.

The authors expanded the analyses to include the CEA that resulted in a total of 245 QALYs. Comparing the direct costs of EFNEP with the alternative of having no program, the New York EFNEP was estimated to have an incremental cost-effectiveness ratio of $19,842 per QALY saved. The program was estimated to lower medical and productivity costs. Previous research estimated that society is willing to pay in excess of $200,000 per QALY. Hence, the willingness-to-pay analysis resulted in a benefit-to-cost ratio of $10.08 to $1.00.

The study also included cost-benefit analyses on two subgroupings of data in an attempt to understand variation across the State from a programmatic perspective. First, the effect of population size and density was investigated by comparing benefit-to-cost ratios across rural counties (<50,000 residents), urban counties (>50,000 residents), and New York City (NYC). Programs in rural areas had the highest benefit-to-cost ratios ($1.05 to $1.00 compared with $0.94 to $1.00 in NYC and $0.56 to $1.00 in other urban areas). The urban result is probably due to several urban programs in the State with overall poor outcomes. Second, the study investigated the effect of different program delivery methods by comparing benefit-to-cost ratios among local programs delivering more than 60 percent of their classes in groups, those delivering more than 60 percent individually, those balanced with 40 to 60 percent delivered in groups and 40 to 60 percent delivered individually, and those using a mixed method in which classes were delivered in groups along with individual contacts with participants. Individual education produced higher benefit-to-cost ratios than group education. The best results were seen among counties that provided a combination of group and individual instruction. This method appeared to improve efficiency and retain the individualized education that had the greatest effect.

Based on state-of-the-art economic analyses, the New York EFNEP lowered cost in terms of projected future health care costs. The authors note that caution should be used when interpreting the study results. Many potential benefits of the program, such as nutrition and food safety benefits to other family members, could not be captured in the study, which leads to an underestimate of the program’s benefits. On the other hand, the people who graduate from EFNEP are probably those who are most likely to benefit from it. Therefore, the program benefits may not be as great for the general population as those estimated for the people who completed the program. However, these results can be used by Federal policymakers to help guide funding decisions, and could also be useful at the State level to guide decisions about funding and program changes to improve health outcomes.