Nutrition Education: USDA Provides Services through Multiple
Programs, but Stronger Linkages among Efforts Are Needed
(27-APR-04, GAO-04-528).
The Centers for Disease Control and Prevention recently reported
that poor nutrition and lack of physical activity are catching up
to tobacco use as the leading cause of death in the United
States. In addition to having negative health outcomes, children
with poor nutrition may have a harder time succeeding in school
than other children. To help improve nutrition, the U.S.
Department of Agriculture (USDA) provides nutrition education
through five of its programs. The department spent $472 million
on these efforts in fiscal year 2002. GAO was asked: (1) What key
actions can officials take to increase the likelihood of success
in nutrition education? (2) Do USDA and state and local officials
take these actions during program design, service delivery, and
program monitoring and evaluation?
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-04-528
ACCNO: A09852
TITLE: Nutrition Education: USDA Provides Services through
Multiple Programs, but Stronger Linkages among Efforts Are Needed
DATE: 04/27/2004
SUBJECT: Children
Education program evaluation
Food programs for children
Nutrition research
Strategic planning
Nutrition
Food Stamp Program
National School Lunch Program
Special Supplemental Nutrition Program
for Women, Infants and Children
USDA Adult Expanded Food and Nutrition
Education Program
USDA Child and Adult Care Food Program
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GAO-04-528
United States General Accounting Office
GAO
Report to the Committee on
Agriculture, Nutrition, and Forestry U.S. Senate
April 2004
NUTRITION
EDUCATION
USDA Provides Services through Multiple Programs, but Stronger Linkages among
Efforts Are Needed
GAO-04-528
Highlights of GAO-04-528, a report to the Committee on Agriculture,
Nutrition, and Forestry, U.S. Senate
The Centers for Disease Control and Prevention recently reported that poor
nutrition and lack of physical activity are catching up to tobacco use as
the leading cause of death in the United States. In addition to having
negative health outcomes, children with poor nutrition may have a harder
time succeeding in school than other children. To help improve nutrition,
the U.S. Department of Agriculture (USDA) provides nutrition education
through five of its programs. The department spent $472 million on these
efforts in fiscal year 2002.
GAO was asked: (1) What key actions can officials take to increase the
likelihood of success in nutrition education? (2) Do USDA and state and
local officials take these actions during program design, service
delivery, and program monitoring and evaluation?
GAO recommends that the Secretary of Agriculture develop a unifying
strategy for USDA's nutrition education efforts that (1) identifies ways
to improve coordination efforts and strengthen the linkages among the
nutrition education efforts and (2) explores options to improve program
monitoring and evaluation by collecting reliable data on services and
recipients, identifying and disseminating lessons learned, and considering
a longer-term evaluation strategy.
www.gao.gov/cgi-bin/getrpt?GAO-04-528.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact David Bellis at (415)
904-2272 or [email protected].
April 2004
NUTRITION EDUCATION
USDA Provides Services through Multiple Programs, but Stronger Linkages among
Efforts Are Needed
GAO identified several key actions, based on research and performancebased
management principles, that increase the likelihood that programs
providing nutrition education will achieve their goals. As the figure
below shows, examples of these actions include identifying program goals,
tailoring services to meet the needs of participants, and collecting data
on program results. The actions can be taken during program design,
service delivery, and program monitoring and evaluation.
Key Actions That Increase the Likelihood of Successful Nutrition Education
Source: GAO analysis of nutrition education research, performance-based
management principles, and expert interviews.
USDA programs providing nutrition education that we reviewed-the Food
Stamps Program; the Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC); the National School Lunch Program; the Child
and Adult Care Food Program; and the Expanded Food and Nutrition Education
Program-generally incorporated the key program design actions likely to
contribute to success. For example, the USDA programs identified nutrition
education goals and target populations. However, the programs'
administrative structures hinder coordination among the USDA nutrition
education efforts.
We found that the USDA programs incorporated the service delivery actions
likely to contribute to successful nutrition education in different ways
and to varying extents, but they faced similar challenges that affected
their ability to fully incorporate these actions. The challenges included
limited resources and systems for providing nutrition education and
competing program requirements that took time or resources away from
nutrition education. For example, WIC officials said they had limited time
for nutrition education because of competing requirements, such as
providing information on drug and alcohol counseling.
USDA's nutrition education efforts did not fully incorporate the
monitoring and evaluation actions that contribute to success, such as
collecting data on the types of nutrition education provided and the
outcomes of the efforts. As a result, little is known about what nutrition
education is provided and whether these programs have met their nutrition
education goals.
Contents
Letter
Results in Brief
Background
Several Actions Are Key to Performance-Based Management and Successful
Nutrition Education
Although USDA Generally Incorporates the Key Program Design Actions Likely
to Contribute to Success, Establishing Linkages among Programs Is
Difficult
Programs Incorporated the Service Delivery Actions in Different Ways and
to Varying Extents but Faced Similar Challenges to Incorporating Them
Programs Generally Did Not Incorporate Key Nutrition Education Evaluation
Actions, Leaving Officials with Limited Information about Program Results
Conclusions
Recommendations for Executive Action
Agency Comments
1
3 6
13
19
25
34 41 42 43
Appendix I Scope and Methodology
Appendix II Nutrition Education Goals of Key USDA Programs
Appendix III GAO Contacts and Staff Acknowledgments 51
GAO Contacts 51 Staff Acknowledgments 51
Tables
Table 1: Characteristics of EFNEP 8 Table 2: Characteristics of WIC 9
Table 3: Characteristics of FSP 10 Table 4: Characteristics of NSLP and
CACFP 12 Table 5: USDA's Nutrition Education Programs Target Similar
Populations and Have Overlapping Eligibility Requirements 20 Table 6:
Studies of the Nutrition Education Efforts Included in Our Review 40
Table 7: 15 Studies on Nutrition Education in WIC, FSNE, Team Nutrition
(NSLP and CACFP), and EFNEP 49
Figures
Figure 1: USDA Nutrition Education Expenditures Have Increased Overall
between Fiscal Years 1992 and 2002 13 Figure 2: Key Actions That Increase
the Likelihood of Successful Nutrition Education 15
Abbreviations
CACFP Child and Adult Care Food Program CSREES Cooperative State Research,
Education,
and Extension Service EFNEP Expanded Food and Nutrition Education Program
FNS Food and Nutrition Service FSNE Food Stamp Nutrition Education FSP
Food Stamp Program NSLP National School Lunch Program TANF Temporary
Assistance for Needy Families USDA U.S. Department of Agriculture WIC
Special Supplemental Nutrition Program for Women,
Infants, and Children
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
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copyright holder may be necessary if you wish to reproduce this material
separately.
United States General Accounting Office Washington, DC 20548
April 27, 2004
The Honorable Thad Cochran
Chairman
The Honorable Tom Harkin
Ranking Democratic Member
Committee on Agriculture, Nutrition, and Forestry
United States Senate
The Centers for Disease Control and Prevention (CDC) recently reported
that poor nutrition and lack of physical activity are catching up to
tobacco
use as the leading cause of death in the United States.1 Poor nutrition
has
increased dramatically in recent decades and now accounts for about
300,000 preventable deaths each year. The proportion of the nation's
children who are overweight nearly doubled over the last two decades,
and the proportion of adolescents who are overweight almost tripled in
the same period. Furthermore, between 1999 and 2000, two out of every
three adults were obese or overweight. In addition to having negative
health outcomes, children with poor nutrition may have a harder time
concentrating and succeeding in school than other children.2 As a result,
the nation is focusing more attention on the importance of good nutrition.
The U.S. Department of Agriculture (USDA), the lead agency for the
nation's nutrition education efforts, funds and administers a variety of
nutrition education efforts.3 One program, the Expanded Food and
Nutrition Education Program (EFNEP), is designed specifically to provide
nutrition education. In addition, four of USDA's largest nutrition
assistance programs,4 while designed primarily to ensure that eligible
1The data reported in the CDC study came from Ali Mokdad et al., "Actual
Causes of Death in The United States, 2000" JAMA; Mar 10, 2004; 291, 10;
Health Module p. 1238.
2"Children's Nutrition and Learning," ERIC Digest, ED369579, June 1994.
3For the purposes of this report, nutrition education is defined as any
set of learning experiences designed to facilitate the voluntary adoption
of eating and other nutritionrelated behaviors conducive to health and
well-being.
4The USDA also provides nutrition education in a few other programs, such
as the Food Distribution Program on Indian Reservations and the Commodity
Supplemental Food Program. However, we did not include these programs in
our review because they do not receive as large a share of overall federal
program funds as the programs we review in this report.
individuals have access to low-cost or free food, also include nutrition
education components. These programs are the Food Stamp Program (FSP); the
Special Supplemental Nutrition Program for Women, Infants, and Children
(WIC); the National School Lunch Program (NSLP); and the Child and Adult
Care Food Program (CACFP). Together, they reached one in five Americans,
from infants to the elderly, in 2002. Each of these programs has its own
administrative structure, resources, and guidelines for providing
nutrition education.5 In addition, two different USDA agencies oversee the
programs; the Cooperative State Research, Education, and Extension Service
(CSREES) oversees EFNEP,6 and the Food and Nutrition Service (FNS)
oversees the four nutrition assistance programs. Only two of the programs
have legislative requirements to provide nutrition education-EFNEP and
WIC. Together, resources for nutrition education in these programs totaled
about $472 million in fiscal year 2002. Depending on the program,
nutrition education funds ranged from nearly $10 million to almost $250
million in fiscal year 2002, and programs spent between $0.20 and $103 per
participant on nutrition education in that same year, according to USDA
officials.
In view of the importance of good nutrition, you asked us to answer the
following questions: (1) What key actions can officials take to increase
the likelihood of success in nutrition education? (2) Do USDA, state, and
local officials incorporate these actions into their nutrition education
efforts during program design? (3) Do these officials incorporate these
actions during service delivery? (4) Do these officials incorporate these
actions during program evaluation?
To identify the key components believed to contribute to successful
nutrition education, we conducted interviews with experts in the field of
nutrition education research, reviewed key research on the topic, and
reviewed GAO reports and other documents on performance-based
5Two of the programs-NSLP and CACFP-rely primarily on an initiative called
Team Nutrition to support their USDA-sponsored nutrition education
efforts. Team Nutrition funds the development and dissemination of
nutrition education materials for these child nutrition programs.
6CSREES has responsibility for research, academic programs, and
Cooperative Extension, which a USDA official says positions it well for
the design, delivery, and accountability of nutrition education.
management.7 To answer the questions related to USDA's nutrition education
efforts, we conducted interviews with officials from each of the five USDA
programs and reviewed program reports and studies. We also conducted
interviews with cognizant state and local officials from each of the five
programs in three states; we conducted site visits in Maryland and
California and conducted telephone interviews with Michigan officials. We
selected these states because they represented a range of geographic
locations and received a range of funding levels for nutrition education.
Our observations on the delivery of nutrition education are primarily
based on our site visits and cannot be generalized to the programs
nationwide. Finally, we identified and reviewed studies and evaluations of
the programs' nutrition education efforts that were conducted over the
last 10 years to determine whether these programs were meeting their
nutrition education goals. (See app. I for more information on our scope
and methodology.) We conducted our study from May 2003 to April 2004 in
accordance with generally accepted auditing standards.8
We identified several key actions that increase the likelihood that
nutrition education will succeed in achieving its goals, based upon
research on nutrition education, prior GAO reports, and other documents on
performance-based management. The key actions occur in three phases of a
nutrition education effort: program design, service delivery, and program
monitoring and evaluation. First, during program design, responsible
officials need to set clear program goals, identify specific target
populations, and develop strategic plans that outline how the program will
achieve its goals. Second, during the provision of nutrition education
Results in Brief
7Specifically, in our review of nutrition education research, we relied
primarily on one comprehensive research review of 217 nutrition education
studies at the recommendation of USDA officials. See Isobel Contento, "The
Effectiveness of Nutrition Education and Implications for Nutrition
Education Policy, Programs, and Research: A Review of Research," Journal
of Nutrition Education, Vol. 27, No. 6 (December 1995). We also
incorporated information from Dr. Contento's draft 2004 review of
nutrition education research. Regarding GAO reports and other documents on
performance-based management, we relied on our series of reports reviewing
implementation of the Government Performance and Results Act to identify
program design and evaluation strategies related to successful program
management. For example, see U.S. General Accounting Office,
Results-Oriented Government: GPRA Has Established a Solid Foundation for
Achieving Greater Results, GAO-04-38 (Washington D.C.: March 10, 2004).
8For the purposes of our report, we do not include activities such as food
safety and budget management instruction in our definition of nutrition
education. As a result, we did not review EFNEP's food safety and food
resource management education services, nor did we review the nutrition
assistance services of WIC, Food Stamps, NSLP, and CACFP.
services, or service delivery, nutrition educators should assess the needs
of the targeted populations, including nutritional and learning needs, and
appropriately tailor services to meet those needs. For example, in
providing services to non-English-speaking pregnant women, nutrition
educators would need to provide services that addressed the nutritional
needs associated with pregnancy as well as provide those services in the
participant's native language. Nutrition educators should also deliver
services with an appropriate frequency and duration to ensure the content
of the nutrition education services are sufficient to meet the program's
goals. In addition, consistent nutrition messages should come through
multiple channels of communication, which can reinforce positive
nutritional behavior. Third, during program monitoring and evaluation,
officials should monitor the services provided and who receives them,
assess program outcomes, and evaluate whether the program has had the
desired impact on participants. However, even when nutrition education
efforts incorporate all of these actions, certain factors in the
participant's environment, such as the availability of fresh fruits and
vegetables or the prevalence of food advertising, can have a significant
influence on a program's results. Accordingly, officials should be
conscious of what environmental factors are affecting participants and
work to address those factors.
In its nutrition education efforts, USDA generally incorporates the key
program design actions that are likely to contribute to success, such as
identifying target populations and setting nutrition education goals.
However, USDA faces challenges coordinating and building linkages across
the five different programs that provide nutrition education. The USDA
programs share similar target populations and nutrition education goals.
Specifically, the programs target some overlapping populations, such as
low-income families, and each program's nutrition education goals focus on
improving nutritional knowledge and changing dietary behavior. Given these
overlaps, it is important that the programs build effective linkages and
increase coordination efforts to make the most efficient and effective use
of resources. At the federal level, USDA recognizes the value of
coordination efforts among different programs that provide nutrition
education. For example, USDA supports participation in nutrition-related
committees and the sharing of nutrition education materials on a
department Web site. In addition, FNS and EFNEP have identified the need
to take additional steps to increase coordination efforts among its
programs in certain areas. However, there is limited evidence of a
department-wide strategy to build effective linkages between EFNEP and the
FNS programs. In the absence of an overall strategy to better link these
programs, USDA missed opportunities to increase coordination efforts,
such as more systematically planning services and developing programs, as
well as sharing curricula, lessons learned, and data collection tools
across the nutrition education efforts. At the state and local levels,
linkages among programs are hindered by the different funding streams,
personnel, and requirements for designing and delivering nutrition
education for their target populations. For example, in one state we
visited, USDA programs were administered by five different agencies,
ranging from social service and health departments to a Cooperative
Extension office.
We found that the USDA programs incorporated the service delivery actions
likely to contribute to successful nutrition education in different ways
and to varying extents, but they faced similar challenges that affected
their ability to fully incorporate these actions. Service delivery
approaches ranged from one-on-one counseling to broad media campaigns. The
challenges included limited resources and systems for providing nutrition
education and competing program requirements that took time or resources
away from nutrition education. For example, the NSLP and CACFP programs
lack a formal administrative structure to systematically deliver nutrition
education and disseminate the nutrition education materials created by
Team Nutrition. Similarly, although WIC staff members conducted
preliminary needs assessments through basic intake questionnaires, they
could not provide frequent and ongoing services because of limited
resources and competing requirements. Specifically, WIC officials in the
states we studied told us the time they could spend on nutrition education
was limited to less than 20 minutes twice every 6 months per participant,
in part because of requirements that they also provide information on drug
and alcohol counseling, and other non-nutrition information and services.
The programs we reviewed did not fully incorporate the monitoring and
evaluation actions that are key to performance-based management and likely
to contribute to successful nutrition education. Most of the programs-with
the exception of EFNEP-did not systematically monitor its nutrition
education. Specifically, most of the programs did not collect data at the
federal level on the types of nutrition education services provided and
who received these services. For example, WIC does not systematically
collect data at the federal level on the number and characteristics-such
as age, gender, or income level-of participants receiving nutrition
education. Nor does it collect data on the types of nutrition education
provided or the length or frequency of nutrition education. In addition,
most of the programs we reviewed did not collect data on potential
outcomes of nutrition education. For example, only
EFNEP collected data changes in the nutrition knowledge and dietary
behavior of participants. Moreover, none of the programs conducted regular
nationwide evaluations of its nutrition education efforts, largely because
such research can be difficult and costly. Despite the absence of regular
nationwide evaluations, USDA and others have conducted some limited or
smaller-scale evaluations and studies of particular nutrition education
efforts. However, the studies conducted over the last 10 years that we
identified were not of sufficient scope or quality to allow us to
determine whether the programs have met their nutrition education goals.
For example, we identified a number of studies finding that EFNEP improved
participants' nutrition knowledge or dietary behavior, but each of these
was limited to one city or state and did not allow us to determine whether
EFNEP as a whole was meeting its goals. In the absence of key monitoring
and evaluating actions, federal and state officials had limited
information about the nature of nutrition education, potential outcomes of
those efforts, and the impact of their investments in nutrition education.
To help overcome the challenges associated with USDA's nutrition education
efforts and to help programs incorporate the key actions related to
successful nutrition education, we recommend that the Secretary of
Agriculture ensure that the department develop a unifying strategy for its
nutrition education efforts. The unifying strategy should, at a minimum,
identify ways to increase coordination efforts and strengthen linkages
among the nutrition education efforts. It should also explore options to
collect reliable data on services and recipients, identify and disseminate
lessons learned, and consider a longer-term evaluation strategy. USDA
generally agreed with our recommendations and suggested a number of
technical corrections to the report, which we incorporated.
Efforts to educate individuals about the benefits of healthy eating and
nutrition occur at the federal, state, and local levels through a variety
of different agencies and programs. However, the USDA leads the nation's
nutrition education efforts, providing nutrition education through the
EFNEP program and through four of its major nutrition assistance programs.
The extent to which nutrition education is integrated into nutrition
assistance programs varies. In some programs, such as WIC, it is a
mandatory component of the program. In others, it plays a lesser role.
Each program has different legislative requirements and administrative
structures for its nutrition education efforts. In addition, each program
has a particular funding level to support its nutrition education efforts.
Background
USDA Is the Lead Federal Several federal agencies support nutrition
education.9 However, in 1977, Agency Responsible for USDA was named the
lead agency for nutrition research, extension, and Nutrition Education
teaching.10 Among USDA's wide array of responsibilities-including
overseeing the nation's forests, conserving the nation's resources, and
leading the nation's anti-hunger efforts-it provides nutrition education
through the EFNEP program and four of its nutrition assistance programs.
In recent years, USDA has shifted its nutrition education focus from
providing and disseminating nutrition information to more directly
fostering changes in dietary behavior. USDA sets program regulations and
guidelines that support its broad nutrition education goal, which is to
provide an integrated nutrition education program that contributes to a
nutritionally knowledgeable public, motivated to make behavioral change to
promote optimal health and nutritional status. Within USDA, the Center for
Nutrition Policy and Promotion oversees nutrition education policy and
develops and maintains the Dietary Guidelines for Americans and the Food
Guide Pyramid. USDA tries to ensure that its nutrition education
integrates the messages established in USDA's Dietary Guidelines for
Americans and the Food Guide Pyramid;11 these efforts help USDA officials
ensure some consistency across their nutrition education efforts.
Each of USDA's Programs That Provide Nutrition Education Has a Different
Overall Mission, Legislative Requirement, Administering Entity, and
Nutrition Education Funding Level
The five USDA programs that provide nutrition education differ in their
overall mission and their legislative requirements, administering
entities, and funding levels for nutrition education. First, only one of
the five programs-EFNEP-is uniquely a nutrition education program; the
four other programs are primarily nutrition assistance programs. These
programs provide nutrition education through an array of state and local
administering entities, from health and education departments to
Cooperative Extension offices, a network of educators in universities and
county offices. While these programs may differ operationally, they have
the potential to reach a broad population with their nutrition education
efforts.
9Other federal agencies, such as the Department of Health and Human
Services, the Department of Education, and the Department of the Interior,
support nutrition education.
10See Pub. L. No. 95-113.
11USDA recently solicited comments on proposed revisions to the Food Guide
Pyramid.
EFNEP
EFNEP is a federally funded program specifically designed to educate
lowincome families and youth about nutrition and nutrition-related
subjects, such as food safety and food budgeting. (See table 1.) USDA
initiated the program in fiscal year 1969 to help low-income families
better understand nutrition and manage their food resources. EFNEP is
administered at the state level by Cooperative Extension offices, which
oversee the allocation of federal EFNEP funds. Federal EFNEP funds are
allocated to states based on population data from the decennial census.
Cooperative Extension offices then allocate EFNEP funds to county
extension offices by targeting first those counties with the highest
levels of poverty.
Table 1: Characteristics of EFNEP
Program participation in FY2002: 569,000 low-income adults and youth
Federal program expenditures for FY2002: $59 million (appropriated)
Legislative requirement to provide nutrition Yes education (Yes or No):
State administering entity: Cooperative Extension Service
Local administering entity: County Extension offices
Description of nutrition educator: Paraprofessionals and volunteers
Source: USDA and 7 U.S.C. S: 3175-3175e.
WIC
First authorized in 1974, WIC provides supplemental food and nutrition
education to low-income pregnant, breast-feeding, and postpartum women and
to infants and children under age 5. (See table 2.) In fiscal year 2000,
the WIC program served almost half of all infants and about one-quarter of
all children ages 1 through 4 in the United States. WIC is federally
funded, and most of the program's resources are allocated for providing
participants with paper vouchers in exchange for approved foods at grocery
stores, including milk, juice, and cereal. However, federal program
regulations require that each state expend at least one-sixth of its
nutrition services and administration grants on nutrition education. This
education must be offered to all WIC caregivers. However, WIC participants
cannot be denied the other WIC benefits because they do not attend
nutrition education activities.
Table 2: Characteristics of WIC
Program participation in FY2002: 7.5 milliona
Federal program costs for FY2002: Over $4.3 billion
Federal expenditures for nutrition $247 million education for FY2002:
Legislative requirement to provide Yes nutrition education (Yes or No):
State administering entity: 88 state agencies, consisting of state health
departments, Indian tribes, or intertribal councils
Local administering entity: Over 10,000 local service sites or clinics,
including health departments, community centers, and schools, for exampleb
Description of nutrition educator: Dieticians, nurses, or other health
professionals or paraprofessionals
Source: USDA and 42 U.S.C. S: 1786.
aWIC participation data are based on annual averages.
bSome state-level agencies operate the program at both the state and local
levels rather than distributing WIC funds to local agencies.
Food Stamp Program
The Food Stamp Program enables low-income families to purchase nutritious
foods at retail stores with electronic-based benefits. (See table 3.)
While there is no legislative mandate for nutrition education, states have
the option to use administrative funds to provide nutrition education as a
component of the FSP known as Food Stamp Nutrition Education (FSNE).12 In
order to provide nutrition education, the state agency administering FSP
is responsible for submitting a state nutrition education plan for FSNE.
However, state agencies that determine food stamp eligibility generally do
not have the professional staff and experience to provide nutrition
education. Therefore, the traditional providers of nutrition education
under FSNE have mostly been affiliated with the Cooperative Extension
Service, the same entity that administers EFNEP. In addition, state
Nutrition Networks, which include government, nonprofit and business
organizations, have cooperative agreements with FNS to identify and
respond to nutrition problems at the state level.
12FNS reimburses 50 percent of states' allowable expenditures on nutrition
education.
Table 3: Characteristics of FSP
a
Program participation in FY2002: 19.1 million
Federal program costs for FY2002: $20.7 billion (food stamp benefits and
administration)
Federal expenditures for nutrition $156.1 million education for FY2002:
Legislative requirement to provide No nutrition education (Yes or No):
State administering entity: State social service agencies administer the
Food Stamps Program. However, most states contract with USDA's Cooperative
Extension for delivery of nutrition education through FSNE. In some cases,
state nutrition networks, public health departments, welfare agencies, and
university academic centers administer FSNE.
Local administering entity: Social service offices determine eligibility
for food stamp benefits. However, FSNE is usually provided in county
extension offices, community-based centers, schools, day care and Head
Start centers, WIC clinics, etc.
Description of nutrition educator: Professionals or paraprofessionals
Source: USDA and 7 U.S.C S: 2011-2036.
aFSP participation data is based on average monthly participation.
NSLP and CACFP
The NSLP and CACFP programs provide nutritionally balanced meals at low or
no cost. (See table 4.) NSLP provides nutritionally balanced, federally
subsidized meals for all children in public and nonprofit schools and
residential child care institutions, with the size of the subsidy
dependent on the income level of participating households.13 Similarly,
CACFP provides nutritious meals and snacks to children in nonresidential
child care and chronically impaired adults or adults age 60 or older in
nonresidential day care facilities. FNS administers both programs at the
federal level. At the state level, state education agencies typically
administer and monitor the program. For NSLP, funding flows to the local
school food authorities-offices responsible for managing the meals
program. For CACFP, funding flows to sponsoring agencies, generally
13Children from households with incomes at or below 130 percent of the
federal poverty level are eligible for free meals; those from households
with incomes between 130 percent and 185 percent of the poverty level are
eligible for reduced-price meals; and those from households above 185
percent of poverty pay full price. Also see U.S. General Accounting
Office, School Meal Programs: Estimated Costs for Three Administrative
Processes at Selected Locations, GAO-02-944 (Washington D.C.: September
25, 2002).
nonprofit agencies. Neither program has a legislative requirement to
provide nutrition education, and unlike EFNEP and the other FNS programs,
neither NSLP nor CACFP has funding specifically to support nutrition
education. However, USDA established the Team Nutrition initiative in 1995
to promote nutrition education activities through these child nutrition
programs.14 Specifically, Team Nutrition provides grants to states and
develops and disseminates technical assistance materials on how to build
school and community support for healthy eating, physical activity, and a
healthy nutrition environment. However, while Team Nutrition, which was
funded at $10 million in fiscal year 2002, funds the development of
nutrition education messages and materials, it does not fund the staff and
other resources needed to deliver nutrition education.
14USDA intended Team Nutrition to work in conjunction with the Nutrition
Education and Training (NET) Program in an effort to improve the nutrition
and eating environment of schools and day care centers. NET helped provide
the manpower and resources needed for state and local officials to
coordinate child nutrition programs with nutrition education activities in
schools and child care centers. However, funding for the NET program has
not been appropriated since fiscal year 1998. Team Nutrition now serves a
primary, rather than supportive, role in providing nutrition education
through NSLP and CACFP.
Table 4: Characteristics of NSLP and CACFP NSLP CACFP
Program participation in a28 million 2.9 millionb
FY2002: children
Federal program costs for $6.1 billion $1.9 billion
FY2002:
Federal expenditures for $10 million through
nutrition Team
education for FY2002: Nutrition
Legislative requirement to No
provide
nutrition education (Yes or
No):
State administering entity: Local administering entity:
Description of nutrition educator:
Department of education Department of education, health, or social
services
Public and private nonprofit Child care centers, schools and residential
child after-school and care institutions Head Start centers,
and day care homes
School food service Day care providers personnel and teachers
Source: USDA and 42 U.S.C. S: 1751-1770.
a NSLP participation data are based on 9-month averages.
b Participation data represent average daily attendance with no adjustment
for absenteeism. Data were collected monthly through fiscal year 1982, and
quarterly in subsequent years.
Overall Funding for As shown in figure 1, funding for nutrition education
has grown over the Nutrition Education Has last decade, primarily driven
by increases in WIC and FSNE; funding for Grown over the Last Team
Nutrition and EFNEP has remained relatively stable or grown only Decade
slightly.
Figure 1: USDA Nutrition Education Expenditures Have Increased Overall
between Fiscal Years 1992 and 2002
Nutrition education funds (dollars in millions)
300
250
200
150
100
50
0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Fiscal year
Food Stamp Nutrition Education
Team Nutrition
WIC
EFNEP
Source: USDA.
Note: All funding amounts are based on expenditures with the exception of
EFNEP funding data, which are based on appropriations.
Several actions are key to performance-based management and likely to
contribute to successful nutrition education, based upon nutrition
education research, prior GAO reports, and other documents on
performance-based management. On the basis of this work, program officials
should take these actions during program design, service delivery, and
program monitoring and evaluation. During service delivery, nutrition
educators need to assess participants' needs and tailor services to meet
those needs. Providing consistent messages through multiple delivery
channels is also beneficial to encouraging a positive change in a
participant's nutritional behavior. Last, during program monitoring and
evaluation, officials need to collect and monitor program service and
participant data, assess outcomes, and evaluate whether the nutrition
education has had the desired impact. Research indicates that, along with
these key actions, environmental factors can have a significant positive
or negative influence on the results of nutrition education and should be
Several Actions Are Key to Performance-Based Management and Successful
Nutrition Education
considered when designing, delivering, and monitoring and evaluating
nutrition education efforts.
Key Actions in Nutrition Education Can Increase the Likelihood of
Success
We identified several key actions presented in general nutrition education
research, prior GAO reports, and other documents on performance-based
management that program officials should take during any nutrition
education program. These actions reflect an ideal. However, if seriously
addressed, these actions will increase the likelihood that the nutrition
education will achieve its goals. These actions occur at three separate
stages in a nutrition education program: program design, service delivery,
and program monitoring and evaluation. However, the framework does not
prescribe a single method of program design, service delivery, or program
monitoring and evaluation; broad principles underpin these actions, which
allows for flexibility, multiple approaches to nutrition education
delivery, and various contexts in which nutrition education can take
place. Figure 2 depicts these actions and the three stages in which they
occur.
Figure 2: Key Actions That Increase the Likelihood of Successful Nutrition
Education
Source: GAO analysis of a comprehensive research review of 217 nutrition
education studies (by Contento, I.), GAO reports and other documents on
performance-based management, and interviews with several nutrition
education experts.
Note: The lists of examples provided under the bulleted actions and
environmental factors are not exhaustive.
According to this framework, during program design officials need to
identify their specific targeted population, set clear program goals, and
conduct strategic planning, which together provide the necessary
foundation to help guide the rest of the actions. Identifying the target
population can help program officials focus their goals and planning
efforts appropriately. Program goals should be clear and measurable, so
officials can determine whether the program is succeeding. Next, program
officials need to conduct strategic and other planning efforts that detail
how they intend to meet their nutrition education goals. For example,
strategic plans should include the program goals, plus objectives,
performance measures, and strategies that they will use to achieve the
goals and objectives. In addition, plans should also include information
on how program officials will coordinate and plan crosscutting efforts
with other related federal programs.
During service delivery, nutrition educators need to assess the needs of
participants, tailor services to meet those needs, and deliver services of
appropriate frequency and duration to meet program goals. In assessing
participant needs, nutrition educators need to identify the nutritional,
health, and learning needs of the participants and tailor the nutrition
education activities to address those needs. For example, in providing
services to non-English-speaking pregnant women, nutrition educators would
need to provide services that addressed the nutritional and health needs
associated with pregnancy as well as provide those services in the
participant's native language. Programs should support needs assessments
of the targeted population receiving nutrition education services.
Research indicates that individual participant assessments can be a
powerful tool in providing services and are particularly important when
the participant has a high level of nutritional risk, such as in cases of
low hemoglobin levels.15 However, programs may also assess the needs of a
selected group of participants, such as low-income women living in a given
community, and tailor services to meet the group's needs. These broader
assessments can also increase the likelihood of a program's success, and
are often present in efforts that employ social marketing, an
audience-centered approach that features multiple and reinforced channels
of communication along with public policy and environmental changes to
influence behavior.16 In addition, educators who live in the community in
which they teach, referred to as paraprofessionals in the EFNEP program,
may have an enhanced understanding of participant needs.17
15Low hemoglobin levels can be an indication of iron-deficiency anemia.
16Social marketing is a private sector marketing model that can be adapted
to social services, which often makes use of television, radio ads,
videos, and brochures. These materials by themselves do not constitute
social marketing; rather, social marketing entails a comprehensive program
in which these materials are employed as part of the tactics to reach a
target audience. Social marketing also emphasizes the importance of
keeping the target audience and network partners involved in needs
assessment, message development, and refinement of messages and delivery
strategies.
17Research indicates that paraprofessionals must have proper and adequate
training to deliver nutrition education to be beneficial.
Finally, nutrition educators also need to deliver services with an
appropriate frequency and duration to ensure the content of the nutrition
education services is sufficient to meet the program's goals. Experts
agree that positive nutritional behavior change requires active and
sustained participation for a duration that is significantly longer than
what is needed for a gain in nutritional knowledge. Nutrition educators
can help ensure that participants receive a sustained and consistent
message by delivering services through multiple channels. By doing so,
nutrition education messages are supported and emphasized, and also can
increase the likelihood of services reaching participants who may not be
able to come into a traditional classroom to receive the nutrition
education.
During program monitoring and evaluation, program officials need to
collect data and evaluate program impact to monitor their nutrition
education efforts and evaluate the program's influence on participant
behavior. Output data, such as how many participants received services and
what services the program provided, enable officials to monitor general
program operations. Outcome data, such as pre-and postprogram dietary
behavior, provide valuable information on whether a participant's
knowledge or behavior has changed following the nutrition education.
Finally, program evaluations with an experimental or quasi-experimental
design help determine whether it is the nutrition education that caused
the knowledge or behavior changes, rather than other factors. Officials
can use all this information to review their successes and failures,
diagnose problems, and explain results. Officials can then use this
information to retool the program design or service delivery to further
increase the chances of success.18
Environmental Factors Can Challenge or Support Nutrition Education Efforts
A complex set of factors, including circumstances in the participant's
environment outside the classroom, contributes to an individual's
decisions about dietary behavior. Research indicates that these factors
can influence the results of education efforts. For example, food
advertising, lack of support from family members, and easy access to
unhealthful foods can make it more difficult for participants to make the
healthy choices presented in their nutrition education classes. For
example, some, but not all, foods sold in schools separate from the
regulated school meals
18In addition, the Government Performance and Results Act of 1993
encourages agencies to measure program performance by determining the
extent to which program outcomes have been achieved.
program are high in fat, sodium, or added sugars. These foods are
available in many schools and can compete with the more healthful foods
available in schools.19 Outside of the school environment, participants
face additional challenges if healthy foods, such as fruits and
vegetables, are not readily available in local stores. Poverty and
unstable monthly incomes can also affect a family's ability to routinely
eat nutritious foods.
Program officials also described situations when environmental factors may
support nutrition education efforts. For example, one official said the
increasing health concern regarding obesity has generated more community
support for healthy eating choices. In addition, nutrition education
participants in rural communities with an abundance of locally grown
produce and vegetables may find it easier to incorporate some of the
lessons from their programs into their daily diets.
When nutrition education activities address environmental factors that can
work against healthy eating choices or leverage environmental factors that
support healthy choices, they may be more likely to improve participants'
dietary behavior. Social marketing often addresses environmental factors.
For example, through a social marketing approach, local public agencies
could work in partnership with private business to establish produce
sections in convenience stores located in low-income neighborhoods that do
not have grocery stores. By then providing nutrition messages about fresh
fruits and vegetables through multiple channels-such as local media and
other community outlets-the effort may be able to increase local supply
and demand for healthful foods.
19For more information on the types and sources of foods in schools that
compete with the NSLP see Nancy Brenner et al., "Mental Health and Social
Services: Results from the School Health Policies and Program Study 2000,"
Journal of School Health, Volume 71, Number 7, September 2001.
Although USDA Generally Incorporates the Key Program Design Actions Likely to
Contribute to Success, Establishing Linkages among Programs Is Difficult
In its nutrition education efforts, USDA generally incorporates the key
program design actions that are likely to contribute to success, such as
identifying target populations and setting nutrition education goals. The
programs share similar target populations and nutrition education goals,
increasing the need for program officials to work together to make the
most efficient and effective use of resources. However, USDA faces
challenges increasing coordinating efforts and building and strengthening
linkages across the five different programs that provide nutrition
education. At the federal level, USDA recognizes the value of coordination
among different nutrition education efforts. However, there is limited
evidence of a department-wide strategy to build effective linkages among
programs, particularly between EFNEP and the FNS programs.
USDA's Nutrition Education Programs Identified Target Populations and Goals
USDA's nutrition education efforts incorporate the key actions of defining
their target populations and goals. While the programs' target populations
for nutrition education are not identical, there is considerable overlap
among them. (See table 5.) Most of USDA's nutrition education efforts
target primarily low-income individuals and families, although nutrition
education through NSLP or CACFP can target any person in a participating
school or child care or adult day care center.
Almost all of USDA's programs use the same eligibility requirements for
nutrition education that they use for their other services associated with
the program, such as the receipt of WIC vouchers. One program, FSP, grants
waivers to state agencies allowing FSNE to target a broader population
than that of people receiving food stamps. However, states are required to
demonstrate that these nutrition education efforts are generally targeted
to program recipients and that the majority of FSNE participants are
low-income.20
20Specifically, states are required to demonstrate that at least 50
percent of the population targeted has a gross household income that is at
or below 185 percent of poverty.
Table 5: USDA's Nutrition Education Programs Target Similar Populations
and Have Overlapping Eligibility Requirements
Program Target population for nutrition education Eligibility for program
services
EFNEP Low-income youth and low-income families with There are no specific
eligibility requirements, but EFNEP providers
children are encouraged to target EFNEP to families on other types of
lowincome assistance, such as food stamps, or to neighborhoods or schools
with high rates of poverty.
WIC Low-income pregnant, postpartum, and breast185% of poverty or less, and
assessed as having "nutritional risk"a
feeding women; infants; and young children receiving WIC
b
Food Stamp Low-income children and families receiving food 130% of poverty
or less
b
Program stamps
NSLP School children At or below 130% of poverty for free meals, between
130% and
c
185% for reduced price; no restrictions for full-priced meals
CACFP Children in nonresidential day Children 12 and under, migrant
care and adults in workers' children 15 and under,
children 18 and under residing in
day care facilities that residential child care facilities,
participate in CACFP and and
adults over 60 in adult day dfunctionally impaired adults or
care centers or adults over age 60 in care centers
chronically disabled persons in
adult day care
centers
Source: USDA.
aIn 2003, the poverty level for a family of three was $15,260 for the 48
contiguous states. EFNEP does not require participants to provide
eligibility documentation. However, the program specifically targets
audiences located in low-income neighborhoods, schools, community center,
etc.
bIn 2002, all 50 states had approved waivers allowing them to provide
nutrition education funded by the Food Stamp Program to non-food stamp
participants.
cIn school year 2002-2003, USDA reimbursed participating schools $2.14 for
every free lunch meal provided, $1.74 for every reduced price lunch meal
sold, and $0.20 for every other lunch meal served.
dFor more information about the definition of a functionally impaired
adult, see USDA's CACFP regulations under 7 C.F.R. S: 226.2.
All five of the USDA programs that provide nutrition education also share
the overall nutrition education goal to improve nutritional knowledge and
dietary behavior, as shown in appendix II. Officials from each of these
programs told us that state officials have flexibility to set more
specific nutrition education goals. For example, in addition to setting
the federal FSP goal, state FSNE officials in a number of states set the
specific goal of increasing the consumption of fresh fruits and
vegetables.
While USDA sets goals for its nutrition education efforts, the department
does not include measures that specifically assess its nutrition education
efforts. For example, both USDA and FNS have strategic plans that include
the goal of improving the nation's nutrition and health. However, neither
strategic plan includes measures for assessing the effects of the
nutrition education efforts. To assess progress toward its goals, USDA
uses a broad national index-the Healthy Eating Index-a measure of diet
quality
among Americans with incomes under 130 percent of poverty and children in
households under 185 percent of poverty. Although this measure is helpful
in tracking changes in the diet quality of the target population, it is
not tied to participation in nutrition education efforts. Therefore, it is
difficult to determine whether changes in participant behavior are
influenced by program nutrition education efforts or other factors. In
addition, neither USDA's strategic nor its performance plans include other
interim measures that can be more closely linked to program success or
outcomes.
Some Coordinating Efforts Exist across Programs Providing Nutrition
Education, but Strong Linkages Are Absent
When programs have similar goals and serve similar and potentially
overlapping target populations, it is important that some mechanisms exist
that support an array of coordinated activities in order to make the most
efficient and effective use of resources. On one hand, overlap creates the
potential for unnecessary duplication of, or gaps in, service delivery as
well as administrative inefficiencies. On the other hand, overlap between
agencies or programs that administer similar functions is sometimes
necessary to meet federal priorities, and in the case of nutrition
education, participants can benefit from hearing the message from several
sources. To be effective, the messages across programs must be consistent
with one another, which requires established linkages across programs.
USDA recognizes the value of coordinating efforts among these programs; in
practice, the programs coordinate in various ways. FNS and EFNEP staff
participate in multiple committees and initiatives within USDA and with
other federal and nongovernmental organizations to work together on
specific nutritional issues. For example, officials from USDA and the
Department of Health and Human Services participate in a working group to
ensure that dietary guidance from both departments accurately reflects the
Dietary Guidelines for Americans and the Food Guide Pyramid.21
In addition, the programs work with the Food and Nutrition Information
Center (FNIC) at the National Agricultural Library to provide a forum for
the exchange of nutrition education information among programs and with
state and local officials and nutrition educators. However, FNS materials
21USDA also participates in committees that work on nutrition education
with other federal agencies and departments, including the CDC, the
National Cancer Institute (NCI), and the Departments of Education and
Health and Human Services. For example, USDA, CDC, and NCI are part of the
National 5-A-Day Partnership to formulate national strategies and plans to
increase the consumption of fruits and vegetables.
are separate from EFNEP's. FNIC has a memorandum of understanding with
FSNE, WIC, and Team Nutrition to support their nutrition education
materials through FNIC's Web site.22 The Web site houses a wide array of
nutrition education materials, including multiple databases containing
nutrition education curricula. For example, the Web site supports the Food
Stamp Nutrition Connection database, which provides a forum for nutrition
educators to share curricula, participant materials, and other resources
with personnel providing nutrition education activities to food stamp
participants, applicants, and other low-income individuals likely to be
eligible for FSP. Similarly, the Healthy School Meals Resource System
provides information to persons working in USDA's child nutrition
programs. In addition, FNIC also supports links to discussion groups that
allow providers of nutrition education to communicate and exchange ideas.
While there is useful information available through FNIC, we do not know
the extent to which nutrition educators use these resources. Furthermore,
FNIC's Web site does not include either the database of nutrition
education materials created primarily by EFNEP or a link to this database.
Instead, CSREES supports the Nutrition Education for Diverse Audiences
database, which contains nutrition education curricula and other related
material on its Web site.23 These materials can be a valuable resource for
those individuals who take advantage of them; however, USDA does not
systematically ensure coordination or the sharing of materials among the
programs, particularly between FNS and EFNEP.
FNS has identified the need to take additional steps to strengthen the
overall linkages among its programs. For example, as part of the
department's strategic goal to promote healthier eating habits and
lifestyles, it has listed a strategy to support an integrated,
cross-program nutrition education effort to address health-related
problems, such as obesity. However, the plan does not describe the
specific means, mechanism, or responsible authority to implement this
strategy. In addition, FNS has recognized the need for a more integrated,
crossprogram approach in its 1999 report to Congress, the President's
fiscal year 2005 budget request, and other documents. For example, in its
report to Congress,24 FNS states that its goal is to ensure that nutrition
education
22For more information, see http://www.nal.usda.gov/fnic/databases.html.
23See http://www.reeusda.gov/f4hn/efnep/necd.htm.
24U.S. Department of Agriculture, Food and Nutrition Service, Promoting
Healthy Eating: An Investment in the Future (Alexandria, VA: December
1999), ii.
is fully integrated into all FNS programs; specifically, FNS says the
changes needed to enhance nutrition behaviors can only be achieved through
a nutrition education effort that allows flexibility for integrated,
cross-program interventions. In the report, FNS suggests that funding be
authorized for such cross-program coordination. In the budget request, FNS
is requesting a total appropriation of $2.5 million for cross-program
nutrition education efforts, including establishing a cross-program
nutrition framework with the goal of ensuring a comprehensive, integrated,
and family-oriented approach in all FNS nutrition assistance programs.25
The funds would support increased coordinating efforts, such as the
formulation of curricula, the sharing of best practices across FNS program
participants, and the fostering of collaboration among state agencies.
Despite these initiatives and proposals, overall, we found limited
evidence of a department-wide unifying strategy to build and support
effective linkages among the FNS programs and EFNEP that would ensure
consistency of message, efficient use of resources, and planning for
service delivery and program development at the federal level. Increasing
coordination efforts and building strong linkages between EFNEP and FNS
may be challenging because they are administered by two different USDA
agencies. For example, we identified missed opportunities to share data
collection tools and software that could have helped with both program
efficiency and effectiveness. However, some federal officials we spoke
with have recognized the need to improve linkages between the two USDA
agencies. An FNS official said that FNS has begun to focus efforts on ways
to ensure that nutrition messages are coordinated across its programs.
However, it has not yet worked with EFNEP on this issue. An EFNEP official
said that FNS and CSREES are beginning to see the need for enhanced
coordination and have begun to discuss activities that could go in a
memorandum of understanding.
Distinct administrative structures can also create coordination challenges
and fragmented service delivery at the state level and local level.
25The proposed $2.5 million increase would address the lack of funding for
cross-program initiatives and the widely varying levels of nutrition
education within the FNS nutrition assistance programs. Of the $2.5
million, $1.5 million would be used to expand the Eat Smart, Play Hard
nutrition education and promotion campaign and fund the development of
nutrition promotion materials that could be used in more than one program.
The remaining $1 million would be used for new projects that operate
across FNS program boundaries.
Specifically, state and local officials are hindered by the different
administrative structures of each of the programs, including the funding
streams, personnel, and requirements for designing and delivering
nutrition education for their target populations. For example, in one
state we visited, USDA programs were administered by five different
agencies, ranging from social service and health departments to a
Cooperative Extension office. Moreover, states often lack a process or a
central focal point to help coordinate planning efforts among the
programs. In our report on NSLP, we noted that not all states had
established a state focal point for leadership or had begun collaboration
among state agencies to provide nutrition education in schools.26 In the
past, the Nutrition Education and Training Program helped to fund this
central focal point by providing the manpower and resources needed for
state and local officials to coordinate child nutrition programs with
nutrition education activities in schools and child care centers. Despite
the lack of a central focal point, we did find instances of local
coordination across some programs, but this coordination was sporadic and
generally involved two programs rather than all of them.
USDA has taken some steps to encourage and facilitate linkages between
some of its programs that provide nutrition education. At the state level,
FNS established cooperative agreements with 22 states to establish
Nutrition Networks, which can act as the collaborative agent at the state
level to help identify and highlight nutrition problems, such as obesity.
27 Nutrition Networks are state-level organizations that can expand,
coordinate, and integrate innovative nutrition education messages across
programs.28 California's Nutrition Network, for example, includes over 300
government, nonprofit, and business organizations, including the state
26See U.S. General Accounting Office, School Lunch Program: Efforts Needed
to Improve Nutrition and Encourage Healthy Eating, GAO-03-506 (Washington
D.C.: May 9, 2003). In this report, we recommended that the Secretaries of
Agriculture, Health and Human Services, and Education encourage states to
identify a focal point in each state to promote collaborative efforts that
would further develop nutrition education activities for the schools.
27In 1995 and 1996, FNS approved cooperative agreements to establish
Nutrition Networks in 22 states. As of 2002, 19 of the original 22
networks were active and self-sustaining. Additional states are creating
networks or studying the feasibility of creating networks.
28Nutrition Networks comprise state and local government agencies,
nonprofit organizations, and representatives of private industry. The
networks use social marketing techniques, such as providing nutrition
education through public service announcements, using mass media to reach
food stamp participants, and using researched and tailored nutrition
education messages.
Departments of Health Services, Social Services, Education, and Food and
Agriculture, and the state's Cooperative Extension system. State officials
said that one of the many goals of its network is to identify service gaps
across nutrition education efforts. USDA also recently began an initiative
to promote collaboration, known as the State Nutrition Action Plans
initiative. This initiative encourages state agencies to work together
toward a more integrated approach to planning and delivering nutrition
education. When the initiative was launched at its national conference,
FNS asked state officials to work together to identify goals for
collaboration and specific objectives and steps to achieve the goals.
However, the Nutrition Networks are not nationwide, and the State
Nutrition Actions Plans initiative is still in the early stages of
development.
We found that the USDA programs incorporated the service delivery actions
likely to contribute to successful nutrition education in different ways
and to varying extents, but they faced similar challenges that affected
their ability to fully incorporate these actions. Service delivery ranged
from one-on-one counseling to broader media campaigns. However, challenges
such as competing requirements and resource constraints limited each
program's ability to fully incorporate all of the service delivery
actions.
Programs Incorporated the Service Delivery Actions in Different Ways and to
Varying Extents but Faced Similar Challenges to Incorporating Them
EFNEP Incorporated Key Service Delivery Actions, but Services May Not Have
Reached Many Eligible Participants because of Resource Constraints
As the only USDA program we reviewed whose primary mission is to deliver
nutrition education, EFNEP was able to consistently assess participant
needs, tailor services to meet those needs, and provide frequent nutrition
education. However, officials at state Cooperative Extension offices,
EFNEP's administering entity, expressed concern over their ability to
provide equitable services to those in need because of existing funding
formulas and resource constraints.
A federal EFNEP official told us the program assessed participant needs
for nutrition education by routinely having participants fill out either a
food behavior checklist or other questionnaires, which asked about what
the participant had eaten the previous day. These assessments provided
instructors with important indicators of nutrition and dietary behavior.
States had the option of gathering additional information from
participants. For example, California added two more questions to the
assessment form that determined participants' fruit and vegetable intake.
In addition, EFNEP uses paraprofessionals to deliver nutrition education,
and their presence in these communities may augment their ability to
assess local needs. An EFNEP official in Michigan, for example, stated
that having EFNEP paraprofessionals who lived in a Native American
community enhanced their ability to determine the needs of that community.
The EFNEP program has a core curriculum that includes classes on dietary
practice, nutrition quality, food safety, food security, and resource
management. However, EFNEP officials we spoke with stated that the program
allows educators to tailor parts of the curriculum to address
participants' needs. For example, Michigan EFNEP officials told us their
paraprofessionals developed an individual plan for participants tailored
to each participant's responses to questions from the formal needs
assessment.29 The individual plans included the core curriculum of the
particular program but also included areas for emphasis or supplementation
within the curriculum. Similarly, California EFNEP introduced a nutrition
program into public schools called EatFit. With the goal of increasing
nutrition and health among school children, the program included
participant self-assessments, which drove the specific curriculum and
messages provided through the program's series of classes. The children
received tailored interventions, based on the assessments, with goals such
as increasing fruit intake at lunch and increasing physical activity
throughout the school day.
EFNEP officials told us they delivered frequent and ongoing nutrition
education. Specifically, EFNEP educators provided a series of
interventions, which varied in number from 6 to 16, generally in the form
of small group classes over the course of approximately several months to
a year, depending on the number of interventions.30 EFNEP educators
provided nutrition education through various sites, such as WIC clinics,
4-H clubs, community centers, and other key sites in the community.
Research indicates that providing nutrition education through various
sites is beneficial to participants. However, officials noted that while
the delivery of classes over the course of several months helped ensure
29This method of service delivery-highly focused on the individual
participant-can be higher in cost than nutrition education that focuses on
broader groups of participants.
30The core program objectives are set at the national level. However, the
number of classes offered is at the discretion of the local implementing
agency.
participants benefited from the services, this benefit could diminish
after the nutrition education ended.
A federal program official told us that resource constraints and funding
formulas presented challenges for equitable service delivery. Given its
current resources, the program is currently able to fund services in
approximately 700 to 800 of the nation's 3,150 counties. This is, in part,
because EFNEP funding has declined in constant dollars over several
decades despite a general increase in the number of people eligible for
EFNEP services. Furthermore, an EFNEP official said the funding formula
for allocating program resources among states is outdated. It is based on
census data from the 1960s. As a result, states such as California, where
the low-income population has increased over the last two decades, had
less to spend per eligible participant than states with more stable
lowincome populations. For example, while California spent roughly 65
cents per eligible participant in 2003, South Dakota spent over $5.00 per
eligible participant.
Some state and local EFNEP providers delivered nutrition education in
collaboration with other USDA nutrition education programs to broaden
their reach, according to officials with whom we spoke. For example, in
Michigan, EFNEP officials told us they leveraged program resources by
working with the local FSNE initiative to ensure that the geographic areas
where they provided services did not overlap.
WIC's Ability to Incorporate the Key Service Delivery Actions May Have Been
Limited by Competing Program Requirements and Resource Constraints
WIC provides nutrition education services as a part of the program's
overall nutrition assistance mission, but officials we spoke with told us
several competing program requirements and resource constraints limited
the program's ability to fully incorporate all of the service delivery
actions. WIC staff we met with told us their educators, usually
nutritionists or dieticians, routinely assessed participant needs and
usually tailored the services to the needs of the WIC population in
general.31 However, WIC had a limited ability to deliver frequent and
ongoing nutrition education. In addition, other program requirements
restricted the time and resources available for nutrition education.
WIC officials told us that by requiring participants to complete an intake
form that helped providers identify their nutritional intake and dietary
31According to WIC regulations, physicians, registered nurses, physician's
assistants, or state or local medically trained health officials may also
provide WIC services.
behaviors, WIC routinely assessed participants' needs. WIC providers,
which included local public and private nonprofit health clinics and
nonprofit agencies, used these forms to identify high-nutritional-risk
participants, who, according to federal officials, were slated for more
intensive, one-on-one nutritional counseling.32 Some WIC providers we
spoke with also used the intake forms to collect data on the
characteristics and dietary needs of the program participants overall.
Michigan has developed a computer system for collecting and tracking
participant needs that, according to state officials, assisted the state's
local providers in knowing what nutrition education services were most
needed, the number of nutrition education interventions, the number of
participants who refused WIC nutrition education, and the number of
participants enrolled in other programs such as Temporary Assistance for
Needy Families (TANF) and Medicaid.
Federal WIC officials told us that WIC providers try to tailor nutrition
education to participant needs when possible, although in most cases,
participants received nutrition education tailored to the needs of the
overall WIC population. For example, a Michigan official stated that her
staff designed nutrition education classes that were appropriate for the
general WIC community, and participants generally received whatever
predesigned class happened to be offered on the day they were in the
clinic. WIC officials told us that local WIC providers use participant
data to help tailor services. For example, a Maryland WIC official said
the state database included several data elements that are helpful in
tracking local participant health trends, which allowed local clinics to
adjust and develop their overall curriculum to address the needs of the
local participants. Several officials stated that given the limited
resources and time for WIC nutrition education, it was impossible to
ensure participants received nutrition education that addressed their
particular needs except for participants at the greatest nutrition risk.
Federal, state, and local WIC officials we interviewed said the WIC
program had a limited ability to provide frequent and ongoing nutrition
education because of competing program requirements. According to program
rules, WIC providers are required to offer nutrition education to
participants. However, those who do not attend nutrition education
activities cannot be denied the other WIC benefits for their lack of
32According to FNS officials, state officials have the flexibility to set
criteria for their own state to determine what conditions constitute high
nutritional risk.
participation. Moreover, the cost of nutrition education in WIC is a part
of each local agency's administrative expenses, which, according to FNS
officials, forces nutrition education activities to be in competition for
resources with other administrative requirements and duties.33 For
example, WIC providers were required by law to provide services unrelated
to nutrition education, such as voter registration and drug and alcohol
counseling. Because of these competing demands on time and resources, the
average WIC participant received approximately less than 20 minutes of
nutrition education twice every 6 months.34 WIC participants usually
receive WIC services over the course of several years, which allows a more
sustained participation in nutrition education services, according to FNS
officials. However, WIC officials in both California and Michigan stated
that there was little reason to believe such a limited exposure to
nutrition education would produce meaningful changes in a participant's
nutritional knowledge and dietary behavior.
In response to these challenges, FNS and the states we studied were
developing technology-driven approaches to nutrition education. FNS, in
partnership with other organizations, established the WIC Works Resource
System in January 2000. This Web-based system includes an on-line
searchable database of materials developed for WIC audiences and
downloadable materials from the childhood obesity prevention initiative,
Fit WIC. At the state level, Michigan officials told us they were trying
to improve access to services by providing some participants with the
option of receiving services through self-paced Internet classes. In
addition, state WIC officials have collaborated with other USDA efforts to
deliver nutrition education. State officials we interviewed cited examples
of WIC officials working with other programs, such as EFNEP, to develop
nutrition education curricula, but again time, resources, and other
program priorities limited their efforts.
33Although competing requirements limit the time and resources WIC
educators are able to devote to nutrition education services, FNS
officials told us that there is a spending floor for nutrition education
in WIC, which states cannot go below in providing nutrition education
services.
34This is consistent with our prior review of the WIC program. In the
study, we reviewed the services provided by six local WIC agencies, which
were selected using a set of criteria, and found the length of time for
nutrition education services ranged from 4 minutes to 17 minutes per
intervention. See U.S. General Accounting Office, Food Assistance: WIC
Faces Challenges in Providing Nutrition Services, GAO 02-142 (Washington,
D.C.: December 7, 2001).
FSNE's Incorporation of the Service Delivery Actions Varies Widely, and Food
Stamp Recipients May Not Be Receiving FSNE Services
Designed as an optional service for states to provide in conjunction with
other food stamp services, FSNE service delivery varies widely from state
to state. Services in FSNE can range from one-on-one counseling to small
group classes, to broad social marketing campaigns that reach large
numbers of people at a low cost per participant. All of these delivery
methods could incorporate the key delivery actions if implemented
properly. However, not enough is known about the services delivered to
determine whether the service delivery actions are consistently
incorporated across the nation. Moreover, federal and state officials do
not know whether FSNE services are provided to food stamp recipients, the
original intended beneficiaries of the services.
Federal FSNE officials stated that local FSNE educators have the option of
conducting individual needs assessments or of assessing the needs of
larger targeted populations. However, FNS does not provide standard needs
assessment tools. In some cases, according to the same officials, local
FSNE educators are able to use needs assessment tools they developed in
their state or locality. In the states we studied, the state Cooperative
Extension offices that administered EFNEP also administered FSNE. In these
cases, FSNE used a service delivery model similar to EFNEP, which included
individual needs assessments using either a food behavior checklist or
other questionnaire. In California, the State Director of EFNEP told us
these tools might ask about what the participant had eaten in the past 24
hours. FSNE educators reported using information from similar assessment
tools in Michigan to help determine what nutrition education content
participants needed and to identify what nutrition trends were present in
the participant community. In some cases, FSNE used paraprofessionals to
deliver nutrition education services, according to officials from two
states.
On the basis of our site visits and conversations with officials, we found
that FSNE efforts generally tailored most services to the needs of a
targeted group. For example, Michigan FSNE officials told us their
educators went to migrant farm communities to hold classes late at night,
from 9 p.m. to 11 p.m., to accommodate the working and living
circumstances of migrant families. Similarly, FSNE educators went to a
Detroit homeless shelter to teach food safety and preparation relevant to
individuals without stable housing. In California, FSNE officials reported
that their educators tailored the interventions to meet the needs of
non-English-speaking participants by providing information and giving
cooking demonstrations in Vietnamese.
FSNE officials in the states we visited told us FSNE services typically
came through one-time-only interventions. According to FNS officials, a
series of classes provided through classroom instruction was not the usual
form of delivery. Services provided via one-time-only methods can include
media campaigns and other forms of nutrition education designed to reach
participants through multiple channels. These efforts may incorporate the
key service delivery actions, when implemented properly. However, federal
FNS officials told us states' program plans vary widely in their quality
and level of detail, and federal FNS officials did not have a clear
picture of what services local officials provided.35
FNS officials expressed concerns over the rapid growth in FSNE funding in
recent years, combined with states' broad flexibility in implementing the
program. In particular, from 1992 to 2002, the federal funds dedicated for
FSNE services have increased, overall, more than for the other programs.36
Moreover, every state FSNE provider has at least one approved waiver to
allow the provision of nutrition education to non-food stamp recipients,
according to FNS officials. While this waiver permits states to provide
services to a wider range of low-income individuals and eliminates the
administrative burden of checking for Food Stamp Program eligibility, it
also limits any assurance that Food Stamp Program recipients receive FSNE
nutrition education. In fact, FNS officials recognized that at the state
and local level Food Stamp Program officials did not rely on, or
coordinate with, FSNE efforts or officials in any systematic way.
FNS officials said they are currently in the process of proposing changes
to FSNE to address these issues. One of the proposed changes would set
clear policies and strategies for the delivery of services. This change
includes developing a policy framework that describes the intended
structure, target populations, and key behavior changes that FSNE intends
to promote among participants. This policy framework would also set clear
roles for the administrators and stakeholders of FSNE services at the
federal, state, and local levels. In addition to developing this policy
35Although FNS has the ability to reject state plans based on
noncompliance with federal guidelines, FNS officials told us this does not
regularly happen.
36According to officials, state officials may identify noncash resources
as a part of the state's match for federal FSNE funds. According to
officials, the growth in FSNE funds might be due to this ability to
identify public noncash matching funds and private cash donations, as well
as a lack of a cap on the amount of matching funds a state may identify.
framework, FNS is developing systems to disseminate resources and
technical assistance to support state and local FSNE services.
NSLP and CACFP Rely on Team Nutrition to Incorporate the Key Actions, and
Its Capacity is Limited
Because NSLP and CACFP do not have resources or formal systems in place to
provide nutrition education, program officials rely on Team Nutrition to
promote and facilitate nutrition education. Unlike the other programs,
NSLP and CACFP do not fund staff to provide nutrition education. Program
funds are dedicated to the administration, preparation, and delivery of
nutritious meals in school and child care settings. NSLP food service
workers are primarily responsible for the preparation and delivery of
school meals, and CACFP workers may be responsible for providing child
care as well as meals in day care settings. As a result, FNS relies on
Team Nutrition to develop and disseminate education materials and provide
grants and guidance to states, and Team Nutrition is dependent upon the
extent to which child care providers and school personnel find or make
time to devote to nutrition education.
Team Nutrition, which is supported by staff in FNS headquarters, focuses
on a broad array of activities intended to build school and community
support for healthy eating, physical activity, and a healthy school
nutrition environment.37 By doing this, officials told us they hope to
influence the complex set of environmental factors in schools that affect
children's health and their motivation to change their behavior.38 Team
Nutrition promotes a nutrition education curriculum that uses multiple
communication channels to reinforce positive nutrition messages and
encourage students to make healthy choices. Officials we spoke with stated
that Team Nutrition materials are of high quality. The nutrition education
materials are tailored to the broad needs and interests of the children at
specific age and grade levels. The materials use simple graphics to
present complex nutrition messages to broad audiences including students,
parents, and teachers. In addition, Team Nutrition also provides grants to
schools to support their efforts to create a healthy school
37To receive Team Nutrition materials, schools can enroll as a Team
Nutrition school by affirming their commitment to take the lead in making
nutritional changes, conducting nutrition education activities and events,
and using materials from Team Nutrition. In addition, Team Nutrition makes
certain materials and resources available to all schools, including those
that have not enrolled as Team Nutrition schools, on its Web site.
38For example, in addition to developing nutrition education materials,
FNS officials reported that federal staff from Team Nutrition and CDC
collaborate on an ongoing basis to develop materials that address issues
such as offering and promoting nutritious food and beverage options in
vending machines, school stores, and a la carte venues.
environment. However, its financial support for state and local activities
was limited to 21 new competitive grants totaling about $4 million in
fiscal year 2003.
In schools, teachers are uniquely positioned to provide nutrition
education, and Team Nutrition materials are designed for them to use.
However, there is little assurance that these materials systemically reach
teachers and food service workers at the local level. For example, one
school food authority official told us she often does not distribute Team
Nutrition Materials because it is not clear to whom they are targeted. In
addition, principals, teachers, and other officials have stated that
teachers focus classroom time almost entirely on making sure that students
meet state academic standards, leaving little time to include subjects or
because NSLP and CACFP have no systems or infrastructure in place to
support nutrition education delivery at the local level, nutrition
education efforts in schools can often depend on the leadership of only a
few individuals. One California official stated that the NSLP nutrition
education efforts in one particular school district would immediately end
if the school teacher leading the efforts were to leave.
Although food service workers in schools have limited time available for
nutrition education, FNS officials reported that Team Nutrition has
initiated efforts to further promote nutrition education among food
service staff. Team Nutrition staff have attended state meetings of food
service workers and offered to provide local training and resources to
help these staff further incorporate nutrition education into their daily
activities. As of February 2004, FNS had more than 100 requests to conduct
the training at local sites.
Regarding CACFP facilities, officials told us a limited amount of
nutrition education takes place in their program and that children are the
primary recipients of nutrition education services when they are provided.
This further limits the nutrition education provided to adults and the
elderly program participants. In addition, the National Food Service
Management Institute, whose mission is to provide information and services
that promote the continuous improvement of Child Nutrition Programs,
provides information and support for school food service and CACFP
providers.
39Also see GAO-03-506.
Programs Generally Did Not Incorporate Key Nutrition Education Evaluation
Actions, Leaving Officials with Limited Information about Program Results
The programs we reviewed generally did not fully incorporate the
monitoring and evaluation actions that are key to performance-based
management and likely to contribute to successful nutrition education.
Most of the programs-with the exception of EFNEP-did not systematically
collect data at the federal level on the types of nutrition education
services provided, who received these services, and the outcomes of the
services. Moreover, none of the programs we reviewed conducted regular
nationwide evaluations of its nutrition education efforts, largely because
such research can be difficult and costly. Despite the lack of regular
nationwide evaluations, we identified some more limited or smaller-scale
evaluations and studies of the nutrition education efforts conducted by
USDA and others over the last 10 years. However, these studies were not of
sufficient scope or quality to allow us to determine whether the programs
have met their nutrition education goals. As a result, federal and state
officials have limited information about the nature of nutrition
education, potential outcomes of nutrition education efforts, and the
impact of their investments in nutrition education.
Most Programs Did Not Systematically Collect Data on Nutrition Education
Services or Recipients
Most of the programs that provide nutrition education did not
systematically collect data on nutrition education services or recipients
at the federal level. For example, WIC does not systematically collect
data at the federal level on the number and characteristics--such as age,
gender, or income level--of participants receiving nutrition education.40
Nor does it collect data on the types of nutrition education provided or
the length or frequency of nutrition education. Team Nutrition tracks the
overall numbers of educational materials sent to schools but does not have
a mechanism for tracking whether and how the materials are used. FSNE
requires states providing nutrition education to submit some information
on the number of contacts with people or households and on the services
provided, but there is wide variation in the types of information
provided. Moreover, federal officials do not have information about the
demographic characteristics of FSNE recipients or about whether recipients
are also food stamp recipients. Nor do they have a system for tracking the
nationwide frequency of delivery methods such as individual meetings,
classes, media campaigns, or other means. One FSNE official said that
while some states may use the EFNEP data-reporting system to collect
40While WIC collects data on participants in the overall WIC program, the
federal office does not have information on the number or characteristics
of participants who receive nutrition education.
information, FSNE officials do not know how many states use the system and
do not receive data collected through the system unless states choose to
include them in their annual plans.
However, EFNEP, the one program we reviewed that focuses primarily on
nutrition education, regularly collected output data on both services and
recipients. EFNEP gathers a variety of data, including data on the race,
ethnicity, gender, and family size of recipients; whether nutrition
education is provided through group or individual instruction; and the
number of lessons provided.41 The data are collected as part of a
performance reporting system developed to respond to congressional
requests for data on program results. To facilitate data collection and to
produce tailored federal and state reports, the national program office
provides state and local offices with software to record and analyze
client data. Although EFNEP does not require states to use the software,
almost all of the states participating in EFNEP use the software to
provide data on services and recipients.
Without systematic data on nutrition education services and recipients in
each program, federal offices receive inconsistent and incomplete
information about what or how nutrition education is implemented at the
local level and who is being served. A 1996 USDA report noted that the
paucity of data on the department's nutrition education efforts was an
obstacle to effective evaluation of those efforts, and one USDA official
told us that current data collection and monitoring of the nutrition
education efforts continue to be limited. However, some Team Nutrition
officials said they were concerned that requiring states to provide
detailed data on services and recipients would further reduce the limited
resources states have for providing services and might impose reporting
burdens that would discourage states from participating in Team Nutrition.
41We have not reviewed the quality-including the validity and
reliability-of data collected by EFNEP.
Most Programs Did Not Systematically Collect Outcome Data on Their Nutrition
Education Efforts
Most of the programs we reviewed did not systematically collect outcome
data on their nutrition education efforts.42 For example, WIC and Team
Nutrition did not systematically collect data on changes in the nutrition
knowledge or dietary behavior of nutrition education recipients.43 While
most of the programs we reviewed do not require states to provide data on
potential outcomes of nutrition education, states and localities can
choose to collect and assess data themselves. But because such data
collection is optional, most of the programs do not have reliable national
outcome data in consistent formats. For example, Michigan regularly
collects data on FSNE participants' nutrition status before and after
receiving nutrition education in order to track progress toward goals. But
FSNE's federal office does not require such data from participating states
and does not have consistent nationwide outcome data.
However, EFNEP programs across the country measured participants'
nutrition-related knowledge and dietary behavior through a behavior
checklist and a 24-hour recall of food consumption administered at program
entry and exit and reported the data to USDA through their common software
system. EFNEP annually summarizes the outcome data reported by the states,
including the extent to which the nutrient intake of nutrition education
recipients changed after receiving services.44
We have noted in past reports that federal programs that are intended to
influence the behavior of individuals or that provide grants to states
have particular difficulty producing outcome measures.45 For example, we
have
42While outcome data are intended, and generally assumed, to measure the
results of nutrition education services, they do not necessarily include
evidence that the observed changes are caused by the nutrition education
intervention and not by other external factors.
43While WIC collects some data on outcomes of breast-feeding education, it
does not collect other outcome data on the results of nutrition education.
44We have not reviewed the validity or reliability of these outcome
measurement tools. However, one study we reviewed that used EFNEP outcome
data noted that the reliance on self-reported data may lead respondents to
provide socially desirable answers to some questions. See Catherine
Greenwald Arnold and Jeffery Sobal, "Food Practices and Nutrition
Knowledge after Graduation from the Expanded Food and Nutrition Education
Program (EFNEP)," Journal of Nutrition Education, Volume 32, Number 3,
May-June 2000.
45U.S. General Accounting Office, Grant Programs: Design Features Shape
Flexibility, Accountability and Performance Information, GAO/GGD-98-137
(Washington, D.C.: June 22, 1998) and U.S. General Accounting Office, Food
Assistance: Performance Measures for Assessing Three WIC Services,
GAO-01-339 (Washington, D.C.: February 28, 2001).
noted that officials faced obstacles in developing and implementing
outcome measures for WIC nutrition education, including difficulties
identifying effective measures and resource constraints affecting their
ability to collect the data. However, the lack of reliable and systematic
outcome data in most of the programs we reviewed limits the potential for
ongoing monitoring of the nutrition education efforts and for formal
national program evaluation.
None of the Programs Conducted Regular or Nationwide Impact Evaluations of
the Nutrition Education Efforts
None of the programs we reviewed conducted regular nationwide evaluations
assessing the impact of nutrition education efforts. While outcome data
alone provide information about apparent program results, impact
evaluation studies provide stronger evidence that the observed changes in
outcomes-such as improvements in nutrition knowledge and dietary
behavior-are in fact the results of the nutrition education provided.
Without centralized, consistent data on changes in participants' knowledge
and behavior, program officials will have difficulty determining whether
nutrition education efforts are meeting their goals and holding states
accountable for the value of public investments.
Nevertheless, evaluating the nationwide impact of nutrition education can
be challenging because (1) the flexibility and variation within each
nutrition education effort can make it difficult to assess national
progress toward common goals, (2) the lack of consistent national data
makes it difficult to track individual participants' progress and to
expand the scope of an evaluation beyond one state or region, and (3) it
is difficult to isolate a program's effects from other influences. For
example, it may be difficult to determine whether changes in nutrient
intake following nutrition education in the WIC program are due to the
education rather than to the food assistance itself. In addition, it may
be quite challenging to determine to what extent environmental factors,
such as the availability of fresh fruits and vegetables in a particular
area, are responsible for differences in program impact among states and
regions.
Moreover, designing and conducting evaluations that overcome these
challenges can be costly. For example, one official noted that studies
that randomly assign participants to receive either nutrition education or
some other treatment are particularly expensive. USDA officials said that
they are unable to conduct nationwide evaluations of the nutrition
education efforts on a regular basis, largely because of limited funding.
None of the programs we reviewed have funding designated specifically for
research evaluations of their nutrition education efforts. Instead, USDA
conducts research on these efforts using funding for general research
needs.
However, the department must balance the resources needed for nutrition
education research and evaluation with competing demands for research on
other topics.
Instead of regularly evaluating the impact of nutrition education efforts,
the programs conduct occasional studies. Team Nutrition recently conducted
a nationwide evaluation of a comprehensive nutrition education
demonstration program for students, but program officials do not know if
and when a future evaluation will be conducted. Officials noted that the
study consumed about one-half of the total funding that otherwise would
have been available for Team Nutrition state grants in one fiscal year. In
addition, researchers in some states conduct evaluations of aspects of the
USDA nutrition education efforts, but such evaluations are sometimes
limited in geographic scope and in their research designs.
USDA recognizes deficiencies in its current data collection and evaluation
of nutrition education efforts and has taken steps to improve monitoring
and evaluation. A 1996 USDA report to the Secretary found that "a
combination of factors-such as a paucity of data, inadequate funding, and
a change in expected evaluation outcomes-has created a challenging
environment for USDA to assess the overall effectiveness of its nutrition
education activities."46 In addition, FNS's 1999 report to Congress stated
that "the evaluation system for FNS nutrition education is fragmented and
minimal, and lacks outcome measures."47 Noting that reliable data and
evaluation are essential to effective nutrition education planning, FNS
highlighted the need to establish a system for routine data collection to
improve nutrition education planning, management, and outcomes, as well as
ongoing investments in evaluation studies.
Since then, USDA has begun taking steps to collect more useful data and to
improve evaluations of program results. Its efforts to improve FSNE data
collection include a national review of what and how food assistance and
nutrition services are being provided and the development of a uniform
data-reporting system for all states participating in FSNE.48 In
46U.S. Department of Agriculture, The State of Nutrition Education in
USDA: A Report to the Secretary (Washington, D.C.: October 1996), ii.
47Promoting Healthy Eating: An Investment in the Future, ii.
48According to FNS, data that may be collected under the new Education and
Administrative Reporting System include demographic characteristics of
participants receiving nutrition education benefits, information about
state goals, topics covered, outlets, education strategies, and resource
allocations and use.
addition, through efforts including studies, workshops, and an interagency
working group, USDA initiated development of methodology and validation of
instruments for evaluation of FSNE; funded the development of a
methodology for evaluating Team Nutrition; and provided grants and
technical assistance to states to encourage more effective nutrition
education assessment, among other activities. However, we found that these
efforts were generally preliminary steps toward improving monitoring and
evaluation practices.
Available Research Provides Little Information about whether the Programs
Have Met Their Nutrition Education Goals
Despite the lack of regular nationwide evaluations, USDA and others have
conducted some limited or smaller-scale evaluations and studies of the
nutrition education efforts.49 We reviewed this research in order to
determine whether the USDA programs were meeting their nutrition education
goals (see app. II for the programs' nutrition education goals). However,
the research we reviewed is not of sufficient scope and quality to allow
us to determine whether the programs have met their national nutrition
education goals, making it difficult for program officials to know whether
their efforts have been effective.50 We reviewed 20 studies by USDA and
others conducted over the last 10 years that evaluated nutrition education
in the USDA programs (see app. I for a description of our method for
identifying studies and our study review methodology). We eliminated five
studies with major research design limitations that prevented us from
concluding that improvements in nutrition knowledge or dietary behavior
were measured appropriately and were due to the nutrition education
provided rather than to other factors.51 After eliminating the studies
with major research design limitations, 15 studies
49In addition to identifying several multistate evaluations of USDA
nutrition education efforts, we identified more limited studies that
assessed aspects of the nutrition education efforts.
50In order to assess the extent to which USDA nutrition education efforts
were meeting their goals, we reviewed research that specifically evaluated
the USDA nutrition education efforts. In contrast, the key nutrition
education actions we describe in figure 2 are based on an analysis of
research on nutrition education in general. Also, some research has
assessed the impact of certain nutrition assistance programs. See research
cited in GAO-02-142 and Phil Gleason and Carol Suitor, Children's Diets in
the Mid-1990s: Dietary Intake and Its Relationship with School Meal
Participation (Alexandria, Virginia: Mathematica Policy Research Inc. for
the U.S. Department of Agriculture, Food and Nutrition Service, 2001).
However, these studies did not isolate the impact of nutrition education
efforts from the overall nutrition assistance programs.
51Given the methodological challenges of measuring the impact of nutrition
education services on overall health and well-being, studies we reviewed
generally measured the impact of these services on nutrition knowledge and
behavior.
remained in our review, as shown in table 6 (see app. I for a list of
these studies).
Table 6: Studies of the Nutrition Education Efforts Included in Our Review
Studies excluded Special
because of
major research design Program intervention
Program Studies limitations studies studiesa Total
reviewed
EFNEP 10 (2) 7 1
FSNE 2 (1) 0 1
WIC 7 (2) 2 3
Team Nutrition 1 (0) 1 0
Total 20 (5) 10 5
Source: GAO analysis.
aSome of the studies we reviewed assessed the impact of special
interventions or demonstration programs, such as a specially funded effort
to increase fruit and vegetable consumption among WIC nutrition education
recipients, rather than the standard nutrition education efforts.
Of these 15 studies, 8 evaluated nutrition education efforts in EFNEP.
However, 1 of these studies did not assess the impact of standard EFNEP
services; instead, it assessed the impact of an EFNEP special
intervention. While such studies may be useful in developing strategies to
change or strengthen nutrition education, they do not allow us to
determine whether a program as it currently exists is meeting its
nutrition education goals. The remaining 7 studies we reviewed found that
EFNEP improved participants' nutrition knowledge or dietary behavior.
However, because each of these studies was limited to one city or state,
they do not allow us to determine whether EFNEP as a whole is meeting its
goals. Given that states and localities have substantial flexibility in
implementing nutrition education interventions, the program may be meeting
its nutrition goals in some states or regions and not in others. In
addition, most of the EFNEP studies do not compare changes in the
nutrition knowledge and dietary behavior of participants with those of
nonparticipants, limiting their ability to demonstrate that the observed
improvements in knowledge and behavior resulted from the EFNEP services.
Finally, the other 7 studies assessed nutrition education in the nutrition
assistance programs-NSLP and CACFP (through Team Nutrition),52 WIC, and
FSNE. However, these studies do not allow us to determine whether the
programs have met their nutrition education goals because few evaluate
standard nutrition education efforts and because results were sometimes
mixed. Four of the studies assessed the impact of special interventions or
demonstration programs rather than the standard nutrition education
efforts. Of the remaining studies, none evaluated FSNE. And while 1 study
of Team Nutrition among fourth-graders found modest increases in nutrition
knowledge and motivation,53 we did not identify any other studies that
could help us determine whether Team Nutrition had met its program goals.
Finally, we identified 2 studies of standard WIC nutrition education, but
the results of these were mixed. One multistate study found that the
nutrition education efforts improved knowledge and behavior, while another
multistate study found that neither standard WIC nutrition education
efforts nor a special intervention improved knowledge among prenatal
participants.
Over the past few decades, the negative health consequences of poor
nutrition have grown dramatically in the United States. USDA's nutrition
education efforts alone cannot be expected to halt the growing rate of
poor nutrition in the country. However, these efforts could make valuable
contributions to improving nutrition knowledge and positively influencing
dietary behaviors among low-income individuals and schoolchildren.
While only EFNEP is specifically designed to provide nutrition education,
the other nutrition assistance programs are uniquely positioned to provide
nutrition education to a broad range of participants. However, USDA faces
challenges providing nutrition education through these multiple programs
and incorporating the key actions likely to contribute to success.
Moreover, USDA has recognized the need for a cross-program integrated
approach to nutrition education in multiple documents, including its
recent budget proposal. However, although USDA is taking a number of steps
to improve the department's nutrition education activities, it does not
have an overarching strategy for increasing coordination efforts and
Conclusions
52Because CACFP and NSLP provide nutrition education through Team
Nutrition, we identified studies that evaluated Team Nutrition rather than
the two programs.
53This study assessed Team Nutrition efforts that officials said were more
comprehensive than but generally representative of Team Nutrition efforts
nationwide.
strengthening the linkages across its many nutrition education activities.
Without strategies for a more unifying approach to designing, delivering,
and evaluating services across all programs, officials have missed
opportunities to take advantage of the lessons learned from other
nutrition education efforts and are less likely to make efficient use of
limited resources.
In addition, most of the nutrition education efforts did not fully
incorporate the monitoring and evaluation actions likely to contribute to
successful nutrition education. Specifically, USDA lacks reliable data on
what nutrition education is provided, the outcomes of the services, and
how they impact nutrition knowledge and dietary behaviors. Properly
developed outcome measures can provide useful information to program
officials, given limited resources for larger program evaluations. USDA
has recognized deficiencies in its current monitoring and evaluation of
certain nutrition education efforts and is taking preliminary steps to
improve them. However, the agency has not developed a comprehensive
agencywide strategy for incorporating the monitoring and evaluation
actions key to successful nutrition education. Such a unified strategy
could help the department manage the costs associated with monitoring.
However, without a strategy to ensure that programs collect reliable data
on services and recipients, share lessons learned in measuring outcomes,
and conduct periodic evaluations, officials will have difficulty holding
programs accountable for meeting their nutrition education goals. Without
holding programs accountable, USDA officials will be unable to maximize
the impact of future investments in nutrition education.
To help overcome the challenges associated with USDA's nutrition education
efforts and to help programs incorporate the key actions related to
successful nutrition education, we recommend that the Secretary of
Agriculture ensure that the department develop a unifying strategy that,
at a minimum:
o Identifies ways to improve coordination efforts and strengthen the
linkages among the nutrition education efforts, which would include
examining options ranging from more systematically sharing nutrition
education resources across programs to identifying and promoting
approaches for federal, state, and local officials to implement
crossprogram strategies to more efficiently use existing resources. In
developing a unifying strategy, the department may need to submit requests
for program changes to Congress.
Recommendations for Executive Action
Agency Comments
o Explores options to collect reliable data on services delivered and
recipients served, and to identify and disseminate lessons learned. A
longer-term evaluation strategy could include planning periodic and
complementary evaluations of the impact of the nutrition education efforts
to the extent possible, in order to make the most efficient use of the
resources available for such evaluations.
We provided a draft of this report to the U.S. Department of Agriculture
for review and comment. On April 6, 2004, FNS officials, including
representatives from each FNS program discussed in the report, provided us
with their oral comments. The officials were in general agreement with the
recommendations. However, they expressed concern about several elements in
the draft report. First, they viewed our description of the key actions
that are likely to contribute to the success of nutrition education as too
restrictive because it gave the impression that there was only one
desirable way to provide nutrition education. They pointed out that
research supports a variety of approaches to providing nutrition
education. For example, the FSNE program permits both classroom activities
as well as broader social marketing approaches, which can reach more
people at a lower cost per person. We agree that various approaches can be
used to provide nutrition education, as long as the key actions in figure
2 are incorporated in some way, and we added language in the report in
response to this comment.
Second, FNS officials believed that our description in the draft report of
the extent to which the programs under review incorporated the key actions
unfairly held their programs to a standard that was not appropriate, given
the role of nutrition education in the various programs, the variety of
appropriate approaches to delivering nutrition education, and the current
funding levels. We agree that nutrition education plays a different role
in each of the programs and adjusted our report to better reflect that
reality and to avoid comparing the programs with one another.
Third, FNS stated that some of the models for nutrition education are much
more expensive than others, and we have more fully acknowledged this in
the report. FNS officials also pointed out that conducting largescale
impact evaluations would be a very costly and difficult endeavor. We agree
with this point and have not recommended that USDA conduct numerous
large-scale evaluations. Instead, we believe that USDA can more carefully
develop a longer-term evaluation strategy that includes plans to conduct
periodic and complementary evaluations of the various programs.
Finally, FNS officials raised concerns over our discussion of the benefits
of program consolidation and the need for more coordination in the draft
report. They pointed out that each program has its own broad mission, and
it would be difficult to pinpoint opportunities for consolidation. Also,
officials highlighted a number of ways that they coordinate on nutrition
education message, resources, and so forth. In response, we included
additional examples of coordination. However, although FNS has taken
measures to increase coordination efforts and strengthen linkages between
its programs, we believe opportunities exist for increased coordination
efforts and stronger linkages among the FNS programs and between FNS and
EFNEP. For example, USDA could encourage EFNEP and the FNS programs to
take a more systematic approach to planning and program development, as
well as compiling and sharing nutrition education curricula and lessons
learned. Coordination at the state level also poses ongoing challenges.
Our recommendation provides the department with flexibility to determine
the most appropriate means to strengthen coordination and improve
linkages.
On April 14, 2004, we also received oral comments from the National
Program Leader for EFNEP on behalf of CSREES. CSREES agrees with our
recommendations, and stated that the report provides a balanced and useful
account of the five key nutrition education programs. CSREES also noted
that we clearly articulated the similarities and differences between the
programs, noting the variation in size, longevity, administrative
oversight, funding, and degree of local adaptation among the programs.
CSREES also particularly noted the relationship between FSNE and the state
and local Cooperative Extension Service, stating that a substantial
portion of FSNE's required 50 percent match comes from universities and
the Cooperative Extension Service. Also, CSREES has taken several steps to
enhance the coordination and accountability of FSNE when its services are
administered through Cooperative Extension offices, including providing
training to FSNE providers and developing a tool to enhance the
communication and evaluation of nutrition education efforts.
In addition, FNS and CSREES also provided us with technical comments,
which we incorporated where appropriate.
We will send copies of this report to the Secretary of Agriculture,
appropriate congressional committees, and other interested parties. In
addition, the report will be available at no charge on GAO's Web site at
http://www.gao.gov.
If you or your staff have any questions or wish to discuss this material,
please call me at (415) 904-2272 or Kay E. Brown at (202) 512-3674.
David D. Bellis Director, Education, Workforce, and Income Security Issues
Appendix I: Scope and Methodology
To identify the key components believed to contribute to successful
nutrition education, we reviewed key research on the topic, reviewed GAO
reports and other documents on performance-based management, and conducted
interviews with experts in the field of nutrition education.1
Specifically, in our review of nutrition education research, we relied
primarily on one comprehensive research review of 217 nutrition education
studies at the recommendation of USDA officials and academic nutrition
education experts.2 We also relied on additional input of several
nutrition education experts. Finally, we reviewed GAO reports and other
documents on performance-based management in order to identify program
design and evaluation strategies related to successful program management.
To answer the questions related to USDA's nutrition education efforts and
program planning elements, we conducted interviews with federal officials
from each of the five USDA programs, examined program reports and studies,
and reviewed relevant laws and regulations. We also conducted interviews
with cognizant state and local officials from each of the five programs in
three states; we conducted site visits in Maryland and California and
conducted telephone interviews with Michigan officials.We selected these
states because they represented a range of geographic locations and
received a range of funding resources for nutrition education. Our
observations on the delivery of nutrition education are primarily based on
our site visits and cannot be generalized to the programs nationwide.
To identify recent studies that evaluate nutrition education within the
five USDA programs we reviewed, we searched relevant databases through
September 2003, such as Agricola, ABI/Inform, Food Science & Technology,
Educational Resources Information Center, and National Technical
Information Service, and reviewed related GAO reports. We also spoke with
nutrition education experts to identify relevant research.While these
programs all offer services in addition to nutrition education, our report
focuses on the nutrition education components of the evaluations.
1Nutrition education experts we interviewed included Tom Baranowski of
Baylor College of Medicine's Children's Nutrition Research Center, Leslie
Lytle of the University of Minnesota's Division of Epidemiology, Isobel
Contento of Columbia University, and officials of the American Dietetic
Association, the American School Food Service Association, and the Society
for Nutrition Education, among others.
2Contento. We also incorporated information from Dr. Contento's draft 2004
review of nutrition education research.
Appendix I: Scope and Methodology
In order to focus on recent research on the nutrition education components
of the USDA programs and to target articles for detailed review, we
identified studies that met the following criteria:
o The document is an original research study or an analysis of research
data, not only a descriptive study, evaluating nutrition education in one
or more of the five programs.
o The document has been published in a refereed medium (for example, a
journal article, book or book chapter, or USDA-issued report).
o The document's publication date is 1994 or later. 3
o The document is in English.
We also asked USDA officials to identify any research assessing whether
the five programs were meeting their nutrition education goals.We then
compared the lists they provided with our own list of studies to ensure
that all studies meeting our criteria were included in our review.
Altogether, 20 items met our criteria for review.Many of the items we
eliminated were published prior to 1994 and therefore do not satisfy our
definition of recent studies. Some items were eliminated because they were
published as reviews or summaries of original research but did not include
any original research. Other items provide descriptive information about
nutrition education recipients and staff but do not evaluate the nutrition
education efforts.
We then conducted detailed reviews of the 20 studies. These reviews
entailed an evaluation of each study's research methodology, including its
research design, sampling frame, selection of measures, data quality,
limitations, and analytic techniques, as well as a summary of its major
findings. We also assessed the extent to which each study was relevant to
assessing whether a program was meeting its nutrition education goals.
One-quarter (5) of the 20 studies had major research design limitations
that prevented us from including their conclusions in our report. For
example, a number of studies included the use of inappropriate comparisons
and comparison groups, and some studies failed to analyze data collected
both before and after nutrition education was provided. For example, one
study of WIC nutrition education in New Mexico was based on data collected
after, but not before, nutrition education was provided,
3A substantial number of studies of EFNEP were published prior to 1994.
Appendix I: Scope and Methodology
allowing a comparison of different delivery methods but not an evaluation
of overall effectiveness.A study of FSNE in Texas used pretest data
collected retrospectively, at the same time as post-test data, limiting
the validity of the data. After eliminating the studies with major
research design limitations, 15 studies remained in our review, as listed
in table 7.
Appendix I: Scope and Methodology
Table 7: 15 Studies on Nutrition Education in WIC, FSNE, Team Nutrition (NSLP
and CACFP), and EFNEP
WIC Studies
Feldman, Robert H. L., Dorothy Damron, Jean Anliker, Michael Ballesteros,
Patricia Langenberg, Carlo DiClemente, and Stephen Havas. "The Effect of
the Maryland WIC 5-A-Day Promotion Program on Participants' Stages of
Change for Fruit and Vegetable Consumption." Health Education & Behavior
27:5 (October 2000):649-663.
Fox, Mary Kay, Nancy Burstein, Jenny Golay, and Cristofer Price. WIC
Nutrition Education Assessment Study: Final Report. Alexandria, Virginia:
Abt Associates Inc. for the U.S. Department of Agriculture, Food and
Nutrition Service, 1998.
Havas, Stephen, Jean Anliker, Dorothy Damron, Patricia Langenberg, Michael
Ballesteros, and Robert Feldman. "Final Results of the Maryland WIC
5-A-Day Promotion Program." American Journal of Public Health 88:8 (1998):
1161-1167.
Randall, Bonnie, Kim Sprague, David B. Connell, and Jenny Golay. WIC
Nutrition Education Demonstration Study: Child Intervention. Alexandria,
Virginia: Abt Associates Inc. for the U.S. Department of Agriculture, Food
and Nutrition Service, 2001.
Randall, Bonnie, Kim Sprague, David B. Connell, and Jenny Golay. WIC
Nutrition Education Demonstration Study: Prenatal Intervention.
Alexandria, Virginia: Abt Associates Inc. for the U.S. Department of
Agriculture, Food and Nutrition Service, 2001.
FSNE Studies
Joy, Amy Block, Nancy Feldman, Mary Lavender Fujii, Linda Garcia, Mark
Hudes, Rita Mitchell, Sybille Bunch, and Diane Metz. "Food Stamp
Recipients Eat More Vegetables after Viewing Nutrition Videos." California
Agriculture 53: 5 (September-October 1999): 24-28.
Team Nutrition (NSLP AND CACFP) Studies
The Story of Team Nutrition: Pilot Study Outcome Report. Alexandria,
Virginia: Prospect Associates and Westat for the U.S. Department of
Agriculture, Food and Nutrition Service, 1998.
EFNEP Studies
Arnold, Catherine Greenwald, and Jeffery Sobal. "Food Practices and
Nutrition Knowledge after Graduation from the Expanded Food and Nutrition
Education Program (EFNEP)." Journal of Nutrition Education 32:3 (May-June
2000): 130-138.
Brink, Muriel S., and Jeffery Sobal. "Retention of Nutrition Knowledge and
Practices among Adult EFNEP Participants." Journal of Nutrition Education
26:2 (March-April 1994): 74-78.
Burney, Janie, and Betsy Haughton. "EFNEP: A Nutrition Education Program
that Demonstrates Cost-Benefit." Journal of the American Dietetic
Association 102 (2002): 39-45.
Cox, Ruby Hurley, Maria Carmen Rita V. Gonzalez-Vigilar, Mary Ann
Novascone, and Irma Silva-Barbeau. "Impact of a Cancer Intervention on
Diet-related Cardiovascular Disease Risks of White and African-American
EFNEP Clients." Journal of Nutrition Education 28:4 (July-August 1996):
209-218.
Dollahite, Jamie, and Michelle Scott-Pierce. "Outcomes of Individual vs.
Group Instruction in EFNEP." Journal of Extension 41:2 (April 2003).
Luccia, Barbara H. D., Mary E. Kunkel, and Katherine L. Cason. "Dietary
Changes by Expanded Food and Nutrition Education Program (EFNEP) Graduates
Are Independent of Program Delivery Method." Journal of Extension 41:3
(June 2003).
Rajgopal, Radhika, Ruby H. Cox, Michael Lambur, and Edwin C.
Lewis."Cost-Benefit Analysis Indicates the Positive Economic Benefits of
the Expanded Food and Nutrition Education Program Related to Chronic
Disease Prevention." Journal of Nutrition Education and Behavior 34:1
(January-February 2002): 26-37.
Wessman, Cory, Connie Betterley, and Helen Jensen. "An Evaluation of the
Costs and Benefits of Iowa's Expanded Food and Nutrition Education Program
(EFNEP): Final Report."Iowa State University Extension, Ames, Iowa, 2000.
Source: GAO analysis.
Appendix II: Nutrition Education Goals of Key USDA Programs
Program Nutrition education goals
EFNEP To assist low-income families and youths in acquiring the
knowledge, skills, attitudes, and changed behavior necessary for
nutritionally sound diets, and to contribute to their personal development
and the improvement of the total family diet and nutritional well-being.
WIC To (1) stress the relationship between proper nutrition and good
health with special emphasis on the nutritional needs of pregnant,
postpartum, and breast-feeding women; infants; and children under 5 years
of age; and raise awareness about the dangers of using substances during
pregnancy and while breast-feeding; and (2) assist the individual who is
at nutritional risk in achieving a positive change in food habits,
resulting in improved nutritional status and in the prevention of
nutrition-related problems through optimal use of supplemental foods and
other nutritious foods.
FSP To provide educational programs that increase, within a limited
budget, the likelihood of food stamp recipients making healthy food
choices and choosing active lifestyles consistent with the most recent
advice reflected in the Dietary Guidelines for Americans and the Food
Guide Pyramid.
NSLP CACFP and NSLP do not have explicit nutrition education goals.
However, both programs use materials developed and disseminated by USDA's
Team Nutrition initiative, which has the goal of improving children's
lifelong eating and physical activity habits by using the principals of
the Dietary Guidelines for Americans and the Food Guide Pyramid. In
addition,
CACFP NSLP encourages schools to use the school food service program to
teach students about good nutrition practices.
Source: USDA.
Appendix III: GAO Contacts and Staff Acknowledgments
GAO Contacts
Staff Acknowledgments
(130272)
Kay E. Brown (202) 512-3674 ([email protected]) Katrina Ryan (415) 904-2114
([email protected])
In addition to the individuals named above, Peter Rumble, Marissa Jones,
Michelle Verbrugge, Peter Bramble, William R. Chatlos, Luann Moy, Daniel
Schwimer, and Corinna Nicolau made key contributions to this report.
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