Nutrition Education
USDA Provides Services through Multiple Programs, but Stronger Linkages among Efforts Are Needed
Gao ID: GAO-04-528 April 27, 2004
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 identified several key actions, based on research and performance-based management principles, that increase the likelihood that programs providing nutrition education will achieve their goals. 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. 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.
Recommendations
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GAO-04-528, Nutrition Education: USDA Provides Services through Multiple Programs, but Stronger Linkages among Efforts Are Needed
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Report to the Committee on Agriculture, Nutrition, and Forestry:
U.S. Senate:
United States General Accounting Office:
GAO:
April 2004:
Nutrition Education:
USDA Provides Services through Multiple Programs, but Stronger Linkages
among Efforts Are Needed:
GAO-04-528:
GAO Highlights:
Highlights of GAO-04-528, a report to the Committee on Agriculture,
Nutrition, and Forestry, U.S. Senate
Why GAO Did This Study:
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?
What GAO Found:
GAO identified several key actions, based on research and performance-
based 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:
[See PDF for image]
[End of figure]
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.
What GAO Recommends:
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 bellisd@gao.gov.
[End of section]
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:
Appendix I: Scope and Methodology:
Appendix II: Nutrition Education Goals of Key USDA Programs:
Appendix III: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Staff Acknowledgments:
Tables:
Table 1: Characteristics of EFNEP:
Table 2: Characteristics of WIC:
Table 3: Characteristics of FSP:
Table 4: Characteristics of NSLP and CACFP:
Table 5: USDA's Nutrition Education Programs Target Similar Populations
and Have Overlapping Eligibility Requirements:
Table 6: Studies of the Nutrition Education Efforts Included in Our
Review:
Table 7: 15 Studies on Nutrition Education in WIC, FSNE, Team Nutrition
(NSLP and CACFP), and EFNEP:
Figures:
Figure 1: USDA Nutrition Education Expenditures Have Increased Overall
between Fiscal Years 1992 and 2002:
Figure 2: Key Actions That Increase the Likelihood of Successful
Nutrition Education:
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:
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.[Footnote 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.[Footnote 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.[Footnote 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,[Footnote 4] while designed primarily to
ensure that eligible 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.[Footnote 5]In addition, two different USDA agencies oversee
the programs; the Cooperative State Research, Education, and Extension
Service (CSREES) oversees EFNEP,[Footnote 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
management.[Footnote 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.[Footnote 8]
Results in Brief:
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 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.
Background:
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.
USDA Is the Lead Federal Agency Responsible for Nutrition Education:
Several federal agencies support nutrition education.[Footnote 9]
However, in 1977, USDA was named the lead agency for nutrition
research, extension, and teaching.[Footnote 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;[Footnote 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.
EFNEP:
EFNEP is a federally funded program specifically designed to educate
low-income 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 education (Yes or No):
Yes.
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. § 3175-3175e.
[End of table]
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 million[A].
Federal program costs for FY2002: Over $4.3 billion.
Federal expenditures for nutrition education for FY2002: $247 million.
Legislative requirement to provide nutrition education (Yes or No): Yes.
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
example[B].
Description of nutrition educator: Dieticians, nurses, or other health
professionals or paraprofessionals.
Source: USDA and 42 U.S.C. § 1786.
[A] WIC participation data are based on annual averages.
[B] Some state-level agencies operate the program at both the state and
local levels rather than distributing WIC funds to local agencies.
[End of table]
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).[Footnote 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.
Table 3: Characteristics of FSP:
Program participation in FY2002: 19.1 million[A].
Federal program costs for FY2002: $20.7 billion (food stamp benefits
and administration).
Federal expenditures for nutrition education for FY2002: $156.1
million.
Legislative requirement to provide nutrition education (Yes or No): 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 § 2011-2036.
[A] FSP participation data is based on average monthly participation.
[End of table]
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.[Footnote 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 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.[Footnote 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.
Table 4: Characteristics of NSLP and CACFP:
Program participation in FY2002:
NSLP: 28 million children[A];
CACFP: 2.9 million[B].
Federal program costs for FY2002:
NSLP: $6.1 billion;
CACFP: $1.9 billion.
Federal expenditures for nutrition education for FY2002:
NSLP: $10 million through Team Nutrition;
CACFP: [Empty].
Legislative requirement to provide nutrition education (Yes or No):
NSLP: No;
CACFP: [Empty].
State administering entity:
NSLP: Department of education;
CACFP: Department of education, health, or social services.
Local administering entity:
NSLP: Public and private nonprofit schools and residential child care
institutions;
CACFP: Child care centers, after-school and Head Start centers, and day
care homes.
Description of nutrition educator:
NSLP: School food service personnel and teachers;
CACFP: Day care providers.
Source: USDA and 42 U.S.C. § 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.
[End of table]
Overall Funding for Nutrition Education Has Grown over the Last Decade:
As shown in figure 1, funding for nutrition education has grown over
the last decade, primarily driven by increases in WIC and FSNE; funding
for Team Nutrition and EFNEP has remained relatively stable or grown
only slightly.
Figure 1: USDA Nutrition Education Expenditures Have Increased Overall
between Fiscal Years 1992 and 2002:
[See PDF for image]
Note: All funding amounts are based on expenditures with the exception
of EFNEP funding data, which are based on appropriations.
[End of figure]
Several Actions Are Key to Performance-Based Management and Successful
Nutrition Education:
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 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:
[See PDF for image]
Note: The lists of examples provided under the bulleted actions and
environmental factors are not exhaustive.
[End of figure]
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.[Footnote
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.[Footnote 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.[Footnote 17]
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.[Footnote
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 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.[Footnote 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.
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.[Footnote 20]
Table 5: USDA's Nutrition Education Programs Target Similar Populations
and Have Overlapping Eligibility Requirements:
Program: EFNEP;
Target population for nutrition education: Low-income youth and low-
income families with children;
Eligibility for program services: There are no specific eligibility
requirements, but EFNEP providers are encouraged to target EFNEP to
families on other types of low-income assistance, such as food stamps,
or to neighborhoods or schools with high rates of poverty.
Program: WIC;
Target population for nutrition education: Low-income pregnant,
postpartum, and breast-feeding women; infants; and young children
receiving WIC;
Eligibility for program services: 185% of poverty or less, and assessed
as having "nutritional risk"[A].
Program: Food Stamp Program;
Target population for nutrition education: Low-income children and
families receiving food stamps[B];
Eligibility for program services: 130% of poverty or less[B].
Program: NSLP;
Target population for nutrition education: School children;
Eligibility for program services: At or below 130% of poverty for free
meals, between 130% and 185% for reduced price; no restrictions for
full-priced meals[C].
Program: CACFP;
Target population for nutrition education: Children in nonresidential
day care and adults in day care facilities that participate in CACFP
and adults over 60 in adult day care centers or chronically disabled
persons in adult day care centers;
Eligibility for program services: Children 12 and under, migrant
workers' children 15 and under, children 18 and under residing in
residential child care facilities, and functionally impaired adults or
adults over age 60 in care centers[D].
Source: USDA.
[A] In 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.
[B] In 2002, all 50 states had approved waivers allowing them to
provide nutrition education funded by the Food Stamp Program to non-
food stamp participants.
[C] In 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.
[D] For more information about the definition of a functionally
impaired adult, see USDA's CACFP regulations under 7 C.F.R. § 226.2.
[End of table]
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.[Footnote 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 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.[Footnote 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.[Footnote 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, cross-
program 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,[Footnote 24] FNS states that its goal is to ensure
that nutrition education 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.[Footnote
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. 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.[Footnote 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.[Footnote 27] Nutrition Networks are state-level
organizations that can expand, coordinate, and integrate innovative
nutrition education messages across programs.[Footnote 28]
California's Nutrition Network, for example, includes over 300
government, nonprofit, and business organizations, including the state
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.
Programs Incorporated the Service Delivery Actions in Different Ways
and to Varying Extents but Faced Similar Challenges to Incorporating
Them:
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.
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.[Footnote 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.[Footnote
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 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 low-income 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.[Footnote 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 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.[Footnote 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 pre-designed 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
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.[Footnote 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.[Footnote 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.
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.[Footnote 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.[Footnote 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 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.[Footnote 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.[Footnote 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
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 information not included on
the state academic standards test.[Footnote 39] Moreover, 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.
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.[Footnote 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
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.[Footnote 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.
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.[Footnote 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.[Footnote 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.[Footnote 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.[Footnote
45] For example, we have 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."[Footnote 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."[Footnote 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.[Footnote 48] In 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.[Footnote 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.[Footnote 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.[Footnote 51] After
eliminating the studies with major research design limitations, 15
studies 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:
Program: EFNEP;
Studies reviewed: 10;
Studies excluded because of major research design limitations: (2);
Program studies: 7;
Special intervention studies[A]: 1;
Total: 8.
Program: FSNE;
Studies reviewed: 2;
Studies excluded because of major research design limitations: (1);
Program studies: 0;
Special intervention studies[A]: 1;
Total: 1.
Program: WIC;
Studies reviewed: 7;
Studies excluded because of major research design limitations: (2);
Program studies: 2;
Special intervention studies[A]: 3;
Total: 5.
Program: Team Nutrition;
Studies reviewed: 1;
Studies excluded because of major research design limitations: (0);
Program studies: 1;
Special intervention studies[A]: 0;
Total: 1.
Program: Total;
Studies reviewed: 20;
Studies excluded because of major research design limitations: (5);
Program studies: 10;
Special intervention studies[A]: 5;
Total: 15.
Source: GAO analysis.
[A] Some 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.
[End of table]
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),[Footnote 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,[Footnote 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.
Conclusions:
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 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.
Recommendations for Executive Action:
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:
* 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 cross-
program strategies to more efficiently use existing resources. In
developing a unifying strategy, the department may need to submit
requests for program changes to Congress.
* 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.
Agency Comments:
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
large-scale 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:
[End of section]
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.[Footnote 54] 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.[Footnote 55] 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. 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:
* 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.
* The document has been published in a refereed medium (for example, a
journal article, book or book chapter, or USDA-issued report).
* The document's publication date is 1994 or later.[Footnote 56]
* 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, 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.
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.
WIC Studies: 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.
WIC Studies: 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.
WIC Studies: 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.
WIC Studies: 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.
WIC 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.
WIC 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.
WIC 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.
WIC Studies: 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.
WIC Studies: Burney, Janie, and Betsy Haughton. "EFNEP: A Nutrition
Education Program that Demonstrates Cost-Benefit." Journal of the
American Dietetic Association 102 (2002): 39-45.
WIC Studies: 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.
WIC Studies: Dollahite, Jamie, and Michelle Scott-Pierce. "Outcomes of
Individual vs. Group Instruction in EFNEP." Journal of Extension 41:2
(April 2003).
WIC Studies: 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).
WIC Studies: 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.
WIC Studies: 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.
[End of table]
[End of section]
Appendix II: Nutrition Education Goals of Key USDA Programs:
Program: EFNEP; Nutrition education goals: 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.
Program: WIC; Nutrition education goals: 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.
Program: FSP; Nutrition education goals: 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.
Program: NSLP; Nutrition education goals: 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, NSLP encourages
schools to use the school food service program to teach students about
good nutrition practices.
Program: CACFP.
Source: USDA.
[End of table]
[End of section]
Appendix III: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Kay E. Brown (202) 512-3674 (brownke@gao.gov) Katrina Ryan (415) 904-
2114 (ryank@gao.gov):
Staff Acknowledgments:
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.
FOOTNOTES
[1] The 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.
[3] For 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 nutrition-related behaviors conducive to
health and well-being.
[4] The 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.
[5] Two 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.
[6] CSREES 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.
[7] 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. 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).
[8] For 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.
[9] Other federal agencies, such as the Department of Health and Human
Services, the Department of Education, and the Department of the
Interior, support nutrition education.
[10] See Pub. L. No. 95-113.
[11] USDA recently solicited comments on proposed revisions to the Food
Guide Pyramid.
[12] FNS reimburses 50 percent of states' allowable expenditures on
nutrition education.
[13] Children 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).
[14] USDA 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.
[15] Low hemoglobin levels can be an indication of iron-deficiency
anemia.
[16] Social 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.
[17] Research indicates that paraprofessionals must have proper and
adequate training to deliver nutrition education to be beneficial.
[18] In 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.
[19] For 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.
[20] Specifically, 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.
[21] USDA 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.
[22] For more information, see http://www.nal.usda.gov/fnic/
databases.html.
[23] See http://www.reeusda.gov/f4hn/efnep/necd.htm.
[24] U.S. Department of Agriculture, Food and Nutrition Service,
Promoting Healthy Eating: An Investment in the Future (Alexandria, VA:
December 1999), ii.
[25] The 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.
[26] See 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.
[27] In 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.
[28] Nutrition 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.
[29] This 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.
[30] The core program objectives are set at the national level.
However, the number of classes offered is at the discretion of the
local implementing agency.
[31] According to WIC regulations, physicians, registered nurses,
physician's assistants, or state or local medically trained health
officials may also provide WIC services.
[32] According to FNS officials, state officials have the flexibility
to set criteria for their own state to determine what conditions
constitute high nutritional risk.
[33] Although 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.
[34] This 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).
[35] Although FNS has the ability to reject state plans based on
noncompliance with federal guidelines, FNS officials told us this does
not regularly happen.
[36] According 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.
[37] To 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.
[38] For 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.
[39] Also see GAO-03-506.
[40] While 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.
[41] We have not reviewed the quality--including the validity and
reliability--of data collected by EFNEP.
[42] While 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.
[43] While WIC collects some data on outcomes of breast-feeding
education, it does not collect other outcome data on the results of
nutrition education.
[44] We 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.
[45] U.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).
[46] U.S. Department of Agriculture, The State of Nutrition Education
in USDA: A Report to the Secretary (Washington, D.C.: October 1996),
ii.
[47] Promoting Healthy Eating: An Investment in the Future, ii.
[48] According 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.
[49] In addition to identifying several multistate evaluations of USDA
nutrition education efforts, we identified more limited studies that
assessed aspects of the nutrition education efforts.
[50] In 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.
[51] Given 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.
[52] Because CACFP and NSLP provide nutrition education through Team
Nutrition, we identified studies that evaluated Team Nutrition rather
than the two programs.
[53] This study assessed Team Nutrition efforts that officials said
were more comprehensive than but generally representative of Team
Nutrition efforts nationwide.
[54] Nutrition 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.
[55] Contento. We also incorporated information from Dr. Contento's
draft 2004 review of nutrition education research.
[56] A substantial number of studies of EFNEP were published prior to
1994.
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