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. However, in 1977,  USDA was named the lead agency for nutrition research, extension, and  teaching.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; 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 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.
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.

		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). 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.
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. 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. 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.

		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.

	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.
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.  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. 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.
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.

		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. 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.
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.
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. 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. 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, 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. 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. 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.  Nutrition Networks are state-level organizations that can expand,  coordinate, and integrate innovative nutrition education messages across  programs. 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. 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. 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.  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. 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. 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. 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.
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.  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. 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.  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. 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. 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. 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. For example, WIC and Team  Nutrition did not systematically collect data on changes in the nutrition  knowledge or dietary behavior of nutrition education recipients. 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.
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. 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.” 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.” 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. 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. 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. 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. 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).
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), 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, 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.

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.  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. 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.    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.

Appendix II: Nutrition Education Goals of Key USDA Programs

	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.

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.
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.
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.

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.

Summary:
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. 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.