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 
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. 

Highlights of GAO-04-528, a report to the 

Committee on Agriculture, Nutrition, and 

Forestry, U.S. Senate 

April 2004

NUTRITION EDUCATION 

USDA Provides Services through Multiple 

Programs, but Stronger Linkages among 

Efforts Are Needed 

GAO identified several key actions, based on research and performancebased management principles, that increase the likelihood that programs 

providing nutrition education will achieve their goals. As the figure below 

shows, examples of these actions include identifying program goals, tailoring 

services to meet the needs of participants, and collecting data on program 

results. The actions can be taken during program design, service delivery, 

and program monitoring and evaluation. 

Key Actions That Increase the Likelihood of Successful Nutrition Education 

Source: GAO analysis of nutrition education research, performance-based management principles, and expert interviews.

ENVIRONMENTAL FACTORS

ENVIRONMENTAL FACTORS

Program design Service delivery Program monitoring 

and evaluation

Set goals, identify targeted 

population, and conduct 

strategic and other planning

Assess needs, tailor services, and 

deliver frequent and ongoing services

Collect data and 

conduct evaluations

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. 

The Centers for Disease Control 

and Prevention recently reported 

that poor nutrition and lack of 

physical activity are catching up to 

tobacco use as the leading cause of 

death in the United States. In 

addition to having negative health 

outcomes, children with poor 

nutrition may have a harder time 

succeeding in school than other 

children. To help improve nutrition, 

the U.S. Department of Agriculture 

(USDA) provides nutrition 

education through five of its 

programs. The department spent 

$472 million on these efforts in 

fiscal year 2002. 

GAO was asked: (1) What key 

actions can officials take to 

increase the likelihood of success 

in nutrition education? (2) Do 

USDA and state and local officials 

take these actions during program 

design, service delivery, and 

program monitoring and 

evaluation? 

GAO recommends that the 

Secretary of Agriculture develop a 

unifying strategy for USDA’s 

nutrition education efforts that 

(1) identifies ways to improve 

coordination efforts and strengthen 

the linkages among the nutrition 

education efforts and (2) explores 

options to improve program 

monitoring and evaluation by 

collecting reliable data on services 

and recipients, identifying and 

disseminating lessons learned, and 

considering a longer-term 

evaluation strategy. 
Page i GAO-04-528 Nutrition Education 

Letter 1

Results in Brief 3

Background 6

Several Actions Are Key to Performance-Based Management and 

Successful Nutrition Education 13

Although USDA Generally Incorporates the Key Program Design 

Actions Likely to Contribute to Success, Establishing Linkages 

among Programs Is Difficult 19

Programs Incorporated the Service Delivery Actions in Different 

Ways and to Varying Extents but Faced Similar Challenges to 

Incorporating Them 25

Programs Generally Did Not Incorporate Key Nutrition Education 

Evaluation Actions, Leaving Officials with Limited Information 

about Program Results 34

Conclusions 41

Recommendations for Executive Action 42

Agency Comments 43

Appendix I Scope and Methodology 46 

Appendix II Nutrition Education Goals of Key USDA Programs 50 

Appendix III GAO Contacts and Staff Acknowledgments 51 

GAO Contacts 51

Staff Acknowledgments 51

Tables 

Table 1: Characteristics of EFNEP 8

Table 2: Characteristics of WIC 9

Table 3: Characteristics of FSP 10

Table 4: Characteristics of NSLP and CACFP 12

Table 5: USDA’s Nutrition Education Programs Target Similar 

Populations and Have Overlapping Eligibility 

Requirements 20

Table 6: Studies of the Nutrition Education Efforts Included in Our 

Review 40

Contents 
Page ii GAO-04-528 Nutrition Education 

Table 7: 15 Studies on Nutrition Education in WIC, FSNE, Team 

Nutrition (NSLP and CACFP), and EFNEP 49

Figures 

Figure 1: USDA Nutrition Education Expenditures Have Increased 

Overall between Fiscal Years 1992 and 2002 13

Figure 2: Key Actions That Increase the Likelihood of Successful 

Nutrition Education 15

Abbreviations 

CACFP Child and Adult Care Food Program 

CSREES Cooperative State Research, Education, 

 and Extension Service 

EFNEP Expanded Food and Nutrition Education Program 

FNS Food and Nutrition Service 

FSNE Food Stamp Nutrition Education 

FSP Food Stamp Program 

NSLP National School Lunch Program 

TANF Temporary Assistance for Needy Families 

USDA U.S. Department of Agriculture 

WIC Special Supplemental Nutrition Program for Women, 

 Infants, and Children 

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Page 1 GAO-04-528 Nutrition Education 

April 27, 2004 

The Honorable Thad Cochran 

Chairman 

The Honorable Tom Harkin 

Ranking Democratic Member 

Committee on Agriculture, Nutrition, and Forestry 

United States Senate 

The Centers for Disease Control and Prevention (CDC) recently reported 

that poor nutrition and lack of physical activity are catching up to tobacco 

use as the leading cause of death in the United States.1

 Poor nutrition has 

increased dramatically in recent decades and now accounts for about 

300,000 preventable deaths each year. The proportion of the nation’s 

children who are overweight nearly doubled over the last two decades, 

and the proportion of adolescents who are overweight almost tripled in 

the same period. Furthermore, between 1999 and 2000, two out of every 

three adults were obese or overweight. In addition to having negative 

health outcomes, children with poor nutrition may have a harder time 

concentrating and succeeding in school than other children.2

 As a result, 

the nation is focusing more attention on the importance of good nutrition. 

The U.S. Department of Agriculture (USDA), the lead agency for the 

nation’s nutrition education efforts, funds and administers a variety of 

nutrition education efforts.3

 One program, the Expanded Food and 

Nutrition Education Program (EFNEP), is designed specifically to provide 

nutrition education. In addition, four of USDA’s largest nutrition 

assistance programs,4

 while designed primarily to ensure that eligible 

 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 nutritionrelated 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. 

United States General Accounting Office 

Washington, DC 20548 
Page 2 GAO-04-528 Nutrition Education 

individuals have access to low-cost or free food, also include nutrition 

education components. These programs are the Food Stamp Program 

(FSP); the Special Supplemental Nutrition Program for Women, Infants, 

and Children (WIC); the National School Lunch Program (NSLP); and the 

Child and Adult Care Food Program (CACFP). Together, they reached one 

in five Americans, from infants to the elderly, in 2002. Each of these 

programs has its own administrative structure, resources, and guidelines 

for providing nutrition education.5 In addition, two different USDA 

agencies oversee the programs; the Cooperative State Research, 

Education, and Extension Service (CSREES) oversees EFNEP,6 and the 

Food and Nutrition Service (FNS) oversees the four nutrition assistance 

programs. Only two of the programs have legislative requirements to 

provide nutrition education—EFNEP and WIC. Together, resources for 

nutrition education in these programs totaled about $472 million in fiscal 

year 2002. Depending on the program, nutrition education funds ranged 

from nearly $10 million to almost $250 million in fiscal year 2002, and 

programs spent between $0.20 and $103 per participant on nutrition 

education in that same year, according to USDA officials. 

In view of the importance of good nutrition, you asked us to answer the 

following questions: (1) What key actions can officials take to increase the 

likelihood of success in nutrition education? (2) Do USDA, state, and local 

officials incorporate these actions into their nutrition education efforts 

during program design? (3) Do these officials incorporate these actions 

during service delivery? (4) Do these officials incorporate these actions 

during program evaluation? 

To identify the key components believed to contribute to successful 

nutrition education, we conducted interviews with experts in the field of 

nutrition education research, reviewed key research on the topic, and 

reviewed GAO reports and other documents on performance-based 

 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. 
Page 3 GAO-04-528 Nutrition Education 

management.7 To answer the questions related to USDA’s nutrition 

education efforts, we conducted interviews with officials from each of the 

five USDA programs and reviewed program reports and studies. We also 

conducted interviews with cognizant state and local officials from each of 

the five programs in three states; we conducted site visits in Maryland and 

California and conducted telephone interviews with Michigan officials. We 

selected these states because they represented a range of geographic 

locations and received a range of funding levels for nutrition education. 

Our observations on the delivery of nutrition education are primarily 

based on our site visits and cannot be generalized to the programs 

nationwide. Finally, we identified and reviewed studies and evaluations of 

the programs' nutrition education efforts that were conducted over the last 

10 years to determine whether these programs were meeting their 

nutrition education goals. (See app. I for more information on our scope 

and methodology.) We conducted our study from May 2003 to April 2004 in 

accordance with generally accepted auditing standards.8

We identified several key actions that increase the likelihood that nutrition 

education will succeed in achieving its goals, based upon research on 

nutrition education, prior GAO reports, and other documents on 

performance-based management. The key actions occur in three phases of 

a nutrition education effort: program design, service delivery, and program 

monitoring and evaluation. First, during program design, responsible 

officials need to set clear program goals, identify specific target 

populations, and develop strategic plans that outline how the program will 

achieve its goals. Second, during the provision of nutrition education 

 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. 

Results in Brief 
Page 4 GAO-04-528 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, 
Page 5 GAO-04-528 Nutrition Education 

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 
Page 6 GAO-04-528 Nutrition Education 

EFNEP collected data changes in the nutrition knowledge and dietary 

behavior of participants. Moreover, none of the programs conducted 

regular nationwide evaluations of its nutrition education efforts, largely 

because such research can be difficult and costly. Despite the absence of 

regular nationwide evaluations, USDA and others have conducted some 

limited or smaller-scale evaluations and studies of particular nutrition 

education efforts. However, the studies conducted over the last 10 years 

that we identified were not of sufficient scope or quality to allow us to 

determine whether the programs have met their nutrition education goals. 

For example, we identified a number of studies finding that EFNEP 

improved participants’ nutrition knowledge or dietary behavior, but each 

of these was limited to one city or state and did not allow us to determine 

whether EFNEP as a whole was meeting its goals. In the absence of key 

monitoring and evaluating actions, federal and state officials had limited 

information about the nature of nutrition education, potential outcomes of 

those efforts, and the impact of their investments in nutrition education.

To help overcome the challenges associated with USDA’s nutrition 

education efforts and to help programs incorporate the key actions related 

to successful nutrition education, we recommend that the Secretary of 

Agriculture ensure that the department develop a unifying strategy for its 

nutrition education efforts. The unifying strategy should, at a minimum, 

identify ways to increase coordination efforts and strengthen linkages 

among the nutrition education efforts. It should also explore options to 

collect reliable data on services and recipients, identify and disseminate 

lessons learned, and consider a longer-term evaluation strategy. USDA 

generally agreed with our recommendations and suggested a number of 

technical corrections to the report, which we incorporated. 

Efforts to educate individuals about the benefits of healthy eating and 

nutrition occur at the federal, state, and local levels through a variety of 

different agencies and programs. However, the USDA leads the nation’s 

nutrition education efforts, providing nutrition education through the 

EFNEP program and through four of its major nutrition assistance 

programs. The extent to which nutrition education is integrated into 

nutrition assistance programs varies. In some programs, such as WIC, it is 

a mandatory component of the program. In others, it plays a lesser role. 

Each program has different legislative requirements and administrative 

structures for its nutrition education efforts. In addition, each program has 

a particular funding level to support its nutrition education efforts. 

Background 
Page 7 GAO-04-528 Nutrition Education 

Several federal agencies support nutrition education.9 However, in 1977, 

USDA was named the lead agency for nutrition research, extension, and 

teaching.10 Among USDA’s wide array of responsibilities—including 

overseeing the nation’s forests, conserving the nation’s resources, and 

leading the nation’s anti-hunger efforts—it provides nutrition education 

through the EFNEP program and four of its nutrition assistance programs. 

In recent years, USDA has shifted its nutrition education focus from 

providing and disseminating nutrition information to more directly 

fostering changes in dietary behavior. USDA sets program regulations and 

guidelines that support its broad nutrition education goal, which is to 

provide an integrated nutrition education program that contributes to a 

nutritionally knowledgeable public, motivated to make behavioral change 

to promote optimal health and nutritional status. Within USDA, the Center 

for Nutrition Policy and Promotion oversees nutrition education policy 

and develops and maintains the Dietary Guidelines for Americans and the 

Food Guide Pyramid. USDA tries to ensure that its nutrition education 

integrates the messages established in USDA’s Dietary Guidelines for 

Americans and the Food Guide Pyramid;11 these efforts help USDA 

officials ensure some consistency across their nutrition education efforts. 

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. 

 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.

10See Pub. L. No. 95-113. 

11USDA recently solicited comments on proposed revisions to the Food Guide Pyramid. 

USDA Is the Lead Federal 

Agency Responsible for 

Nutrition Education 

Each of USDA’s Programs 

That Provide Nutrition 

Education Has a Different 

Overall Mission, 

Legislative Requirement, 

Administering Entity, and 

Nutrition Education 

Funding Level 
Page 8 GAO-04-528 Nutrition Education 

EFNEP is a federally funded program specifically designed to educate lowincome families and youth about nutrition and nutrition-related subjects, 

such as food safety and food budgeting. (See table 1.) USDA initiated the 

program in fiscal year 1969 to help low-income families better understand 

nutrition and manage their food resources. EFNEP is administered at the 

state level by Cooperative Extension offices, which oversee the allocation 

of federal EFNEP funds. Federal EFNEP funds are allocated to states 

based on population data from the decennial census. Cooperative 

Extension offices then allocate EFNEP funds to county extension offices 

by targeting first those counties with the highest levels of poverty. 

Table 1: Characteristics of EFNEP 

Program participation in FY2002: 569,000 low-income adults and youth 

Federal program expenditures for FY2002: $59 million (appropriated) 

Legislative requirement to provide nutrition 

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. 

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. 

EFNEP 

WIC 
Page 9 GAO-04-528 Nutrition Education 

Table 2: Characteristics of WIC 

Program participation in FY2002: 7.5 milliona

Federal program costs for FY2002: Over $4.3 billion 

Federal expenditures for nutrition 

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 exampleb

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. 

The Food Stamp Program enables low-income families to purchase 

nutritious foods at retail stores with electronic-based benefits. (See table 

3.) While there is no legislative mandate for nutrition education, states 

have the option to use administrative funds to provide nutrition education 

as a component of the FSP known as Food Stamp Nutrition Education 

(FSNE).12 In order to provide nutrition education, the state agency 

administering FSP is responsible for submitting a state nutrition education 

plan for FSNE. However, state agencies that determine food stamp 

eligibility generally do not have the professional staff and experience to 

provide nutrition education. Therefore, the traditional providers of 

nutrition education under FSNE have mostly been affiliated with the 

Cooperative Extension Service, the same entity that administers EFNEP. 

In addition, state Nutrition Networks, which include government, 

nonprofit and business organizations, have cooperative agreements with 

FNS to identify and respond to nutrition problems at the state level. 

 12FNS reimburses 50 percent of states’ allowable expenditures on nutrition education. 

Food Stamp Program 
Page 10 GAO-04-528 Nutrition Education 

Table 3: Characteristics of FSP 

Program participation in FY2002: 19.1 milliona

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. 

The NSLP and CACFP programs provide nutritionally balanced meals at 

low or no cost. (See table 4.) NSLP provides nutritionally balanced, 

federally subsidized meals for all children in public and nonprofit schools 

and residential child care institutions, with the size of the subsidy 

dependent on the income level of participating households.13 Similarly, 

CACFP provides nutritious meals and snacks to children in nonresidential 

child care and chronically impaired adults or adults age 60 or older in 

nonresidential day care facilities. FNS administers both programs at the 

federal level. At the state level, state education agencies typically 

administer and monitor the program. For NSLP, funding flows to the local 

school food authorities—offices responsible for managing the meals 

program. For CACFP, funding flows to sponsoring agencies, generally 

 13Children from households with incomes at or below 130 percent of the federal poverty 

level are eligible for free meals; those from households with incomes between 130 percent 

and 185 percent of the poverty level are eligible for reduced-price meals; and those from 

households above 185 percent of poverty pay full price. Also see U.S. General Accounting 

Office, School Meal Programs: Estimated Costs for Three Administrative Processes at 

Selected Locations, GAO-02-944 (Washington D.C.: September 25, 2002). 

NSLP and CACFP 
Page 11 GAO-04-528 Nutrition Education 

nonprofit agencies. Neither program has a legislative requirement to 

provide nutrition education, and unlike EFNEP and the other FNS 

programs, neither NSLP nor CACFP has funding specifically to support 

nutrition education. However, USDA established the Team Nutrition 

initiative in 1995 to promote nutrition education activities through these 

child nutrition programs.14 Specifically, Team Nutrition provides grants to 

states and develops and disseminates technical assistance materials on 

how to build school and community support for healthy eating, physical 

activity, and a healthy nutrition environment. However, while Team 

Nutrition, which was funded at $10 million in fiscal year 2002, funds the 

development of nutrition education messages and materials, it does not 

fund the staff and other resources needed to deliver nutrition education. 

 14USDA intended Team Nutrition to work in conjunction with the Nutrition Education and 

Training (NET) Program in an effort to improve the nutrition and eating environment of 

schools and day care centers. NET helped provide the manpower and resources needed for 

state and local officials to coordinate child nutrition programs with nutrition education 

activities in schools and child care centers. However, funding for the NET program has not 

been appropriated since fiscal year 1998. Team Nutrition now serves a primary, rather than 

supportive, role in providing nutrition education through NSLP and CACFP. 
Page 12 GAO-04-528 Nutrition Education 

Table 4: Characteristics of NSLP and CACFP 

 NSLP CACFP 

Program participation in FY2002: 28 million childrena 2.9 millionb 

Federal program costs for FY2002: $6.1 billion $1.9 billion 

Federal expenditures for nutrition 

education for FY2002: 

$10 million through Team 

Nutrition 

Legislative requirement to provide 

nutrition education (Yes or No): 

No 

State administering entity: Department of education Department of 

education, health, or 

social services 

Local administering entity: Public and private nonprofit 

schools and residential child 

care institutions 

Child care centers, 

after-school and 

Head Start centers, 

and day care homes 

Description of nutrition educator: School food service 

personnel and teachers 

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. 

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. 

Overall Funding for 

Nutrition Education Has 

Grown over the Last 

Decade 
Page 13 GAO-04-528 Nutrition Education 

Figure 1: USDA Nutrition Education Expenditures Have Increased Overall between 

Fiscal Years 1992 and 2002 

Note: All funding amounts are based on expenditures with the exception of EFNEP funding data, 

which are based on appropriations. 

Several actions are key to performance-based management and likely to 

contribute to successful nutrition education, based upon nutrition 

education research, prior GAO reports, and other documents on 

performance-based management. On the basis of this work, program 

officials should take these actions during program design, service delivery, 

and program monitoring and evaluation. During service delivery, nutrition 

educators need to assess participants’ needs and tailor services to meet 

those needs. Providing consistent messages through multiple delivery 

channels is also beneficial to encouraging a positive change in a 

participant’s nutritional behavior. Last, during program monitoring and 

evaluation, officials need to collect and monitor program service and 

participant data, assess outcomes, and evaluate whether the nutrition 

education has had the desired impact. Research indicates that, along with 

these key actions, environmental factors can have a significant positive or 

negative influence on the results of nutrition education and should be 

Several Actions Are 

Key to PerformanceBased Management 

and Successful 

Nutrition Education 

0

50

100

150

200

250

300

EFNEP

WIC

Team Nutrition

Food Stamp Nutrition Education

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Fiscal year

Nutrition education funds (dollars in millions)

Source: USDA.
Page 14 GAO-04-528 Nutrition Education 

considered when designing, delivering, and monitoring and evaluating 

nutrition education efforts. 

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. 

Key Actions in Nutrition 

Education Can Increase 

the Likelihood of Success 
Page 15 GAO-04-528 Nutrition Education 

Figure 2: Key Actions That Increase the Likelihood of Successful Nutrition Education 

Note: The lists of examples provided under the bulleted actions and environmental factors are not 

exhaustive. 

According to this framework, during program design officials need to 

identify their specific targeted population, set clear program goals, and 

conduct strategic planning, which together provide the necessary 

foundation to help guide the rest of the actions. Identifying the target 

population can help program officials focus their goals and planning 

efforts appropriately. Program goals should be clear and measurable, so 

officials can determine whether the program is succeeding. Next, program 

officials need to conduct strategic and other planning efforts that detail 

how they intend to meet their nutrition education goals. For example, 

strategic plans should include the program goals, plus objectives, 

Source: GAO analysis of a comprehensive research review of 217 nutrition education studies (by Contento, I.), GAO reports and other documents on performance-based management, and interviews with 

several nutrition education experts.

MACRO-ENVIRONMENTAL FACTORS: FOOD ADVERTISING,

CULTURAL/COMMUNITY NORMS

MICRO-ENVIRONMENTAL FACTORS: COMPETING FOODS IN SCHOOLS, PARENTAL INVOLVEMENT, 

AVAILABILITY OF HEALTHFUL FOODS

Service delivery

Assess needs 

 Identify nutritional 

 needs

– fruit and vegetable 

 intake, calcium 

 intake

 Identify health needs

– pregnancy, obesity/ 

 overweight, anemia

 Identify learning needs

– literacy level,

 language skills, 

 nutrition knowledge

 Tailor services 

 Ensure 

 developmentally 

 appropriate services

– age, grade level, 

 education abilities

 Develop theory-based

 education approaches

– behavior outcomes,

 learner-focused

 Consider context of 

 services

– clinic, churches,

 groceries

Deliver frequent and 

ongoing services

 Ensure message

 consistency

– frequent and

 ongoing, consistent 

 message

 Use multiple channels 

 and obtain community 

 support

– community centers,

 community leaders, 

 places of worship

Program monitoring 

and evaluation

 Collect output data

– demographic data

 on participants, 

 classes completed

 Collect outcome data

– behavior change,

 improved nutritional

 knowledge

 Conduct formal 

 research and 

 evaluation

– formal studies of

 impact, assess 

 attribution of change

 to nutrition

 education

Program design 

 Identify targeted 

 population

– school-aged, adult, 

 pregnant women, 

 low-income

 Set clear program 

 goals

– behavior change, 

 improved nutritional 

 knowledge

 Conduct strategic and 

 other planning

– coordination, 

 financial and human 

 resources, data

 needs
Page 16 GAO-04-528 Nutrition Education 

performance measures, and strategies that they will use to achieve the 

goals and objectives. In addition, plans should also include information on 

how program officials will coordinate and plan crosscutting efforts with 

other related federal programs. 

During service delivery, nutrition educators need to assess the needs of 

participants, tailor services to meet those needs, and deliver services of 

appropriate frequency and duration to meet program goals. In assessing 

participant needs, nutrition educators need to identify the nutritional, 

health, and learning needs of the participants and tailor the nutrition 

education activities to address those needs. For example, in providing 

services to non-English-speaking pregnant women, nutrition educators 

would need to provide services that addressed the nutritional and health 

needs associated with pregnancy as well as provide those services in the 

participant’s native language. Programs should support needs assessments 

of the targeted population receiving nutrition education services. Research 

indicates that individual participant assessments can be a powerful tool in 

providing services and are particularly important when the participant has 

a high level of nutritional risk, such as in cases of low hemoglobin levels.15

However, programs may also assess the needs of a selected group of 

participants, such as low-income women living in a given community, and 

tailor services to meet the group’s needs. These broader assessments can 

also increase the likelihood of a program’s success, and are often present 

in efforts that employ social marketing, an audience-centered approach 

that features multiple and reinforced channels of communication along 

with public policy and environmental changes to influence behavior.16 In 

addition, educators who live in the community in which they teach, 

referred to as paraprofessionals in the EFNEP program, may have an 

enhanced understanding of participant needs.17 

 15Low hemoglobin levels can be an indication of iron-deficiency anemia. 

16Social marketing is a private sector marketing model that can be adapted to social 

services, which often makes use of television, radio ads, videos, and brochures. These 

materials by themselves do not constitute social marketing; rather, social marketing entails 

a comprehensive program in which these materials are employed as part of the tactics to 

reach a target audience. Social marketing also emphasizes the importance of keeping the 

target audience and network partners involved in needs assessment, message development, 

and refinement of messages and delivery strategies. 

17Research indicates that paraprofessionals must have proper and adequate training to 

deliver nutrition education to be beneficial. 
Page 17 GAO-04-528 Nutrition Education 

Finally, nutrition educators also need to deliver services with an 

appropriate frequency and duration to ensure the content of the nutrition 

education services is sufficient to meet the program’s goals. Experts agree 

that positive nutritional behavior change requires active and sustained 

participation for a duration that is significantly longer than what is needed 

for a gain in nutritional knowledge. Nutrition educators can help ensure 

that participants receive a sustained and consistent message by delivering 

services through multiple channels. By doing so, nutrition education 

messages are supported and emphasized, and also can increase the 

likelihood of services reaching participants who may not be able to come 

into a traditional classroom to receive the nutrition education. 

During program monitoring and evaluation, program officials need to 

collect data and evaluate program impact to monitor their nutrition 

education efforts and evaluate the program’s influence on participant 

behavior. Output data, such as how many participants received services 

and what services the program provided, enable officials to monitor 

general program operations. Outcome data, such as pre- and postprogram 

dietary behavior, provide valuable information on whether a participant’s 

knowledge or behavior has changed following the nutrition education. 

Finally, program evaluations with an experimental or quasi-experimental 

design help determine whether it is the nutrition education that caused the 

knowledge or behavior changes, rather than other factors. Officials can 

use all this information to review their successes and failures, diagnose 

problems, and explain results. Officials can then use this information to 

retool the program design or service delivery to further increase the 

chances of success.18

A complex set of factors, including circumstances in the participant’s 

environment outside the classroom, contributes to an individual’s 

decisions about dietary behavior. Research indicates that these factors can 

influence the results of education efforts. For example, food advertising, 

lack of support from family members, and easy access to unhealthful 

foods can make it more difficult for participants to make the healthy 

choices presented in their nutrition education classes. For example, some, 

but not all, foods sold in schools separate from the regulated school meals 

 18In addition, the Government Performance and Results Act of 1993 encourages agencies to 

measure program performance by determining the extent to which program outcomes have 

been achieved. 

Environmental Factors 

Can Challenge or Support 

Nutrition Education 

Efforts 
Page 18 GAO-04-528 Nutrition Education 

program are high in fat, sodium, or added sugars. These foods are 

available in many schools and can compete with the more healthful foods 

available in schools.19 Outside of the school environment, participants face 

additional challenges if healthy foods, such as fruits and vegetables, are 

not readily available in local stores. Poverty and unstable monthly incomes 

can also affect a family’s ability to routinely eat nutritious foods. 

Program officials also described situations when environmental factors 

may support nutrition education efforts. For example, one official said the 

increasing health concern regarding obesity has generated more 

community support for healthy eating choices. In addition, nutrition 

education participants in rural communities with an abundance of locally 

grown produce and vegetables may find it easier to incorporate some of 

the lessons from their programs into their daily diets. 

When nutrition education activities address environmental factors that can 

work against healthy eating choices or leverage environmental factors that 

support healthy choices, they may be more likely to improve participants’ 

dietary behavior. Social marketing often addresses environmental factors. 

For example, through a social marketing approach, local public agencies 

could work in partnership with private business to establish produce 

sections in convenience stores located in low-income neighborhoods that 

do not have grocery stores. By then providing nutrition messages about 

fresh fruits and vegetables through multiple channels—such as local 

media and other community outlets—the effort may be able to increase 

local supply and demand for healthful foods. 

 19For more information on the types and sources of foods in schools that compete with the 

NSLP see Nancy Brenner et al., “Mental Health and Social Services: Results from the 

School Health Policies and Program Study 2000,” Journal of School Health, Volume 71, 

Number 7, September 2001. 
Page 19 GAO-04-528 Nutrition Education 

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 efforts incorporate the key actions of defining 

their target populations and goals. While the programs’ target populations 

for nutrition education are not identical, there is considerable overlap 

among them. (See table 5.) Most of USDA’s nutrition education efforts 

target primarily low-income individuals and families, although nutrition 

education through NSLP or CACFP can target any person in a participating 

school or child care or adult day care center. 

Almost all of USDA’s programs use the same eligibility requirements for 

nutrition education that they use for their other services associated with 

the program, such as the receipt of WIC vouchers. One program, FSP, 

grants waivers to state agencies allowing FSNE to target a broader 

population than that of people receiving food stamps. However, states are 

required to demonstrate that these nutrition education efforts are 

generally targeted to program recipients and that the majority of FSNE 

participants are low-income.20 

 20Specifically, states are required to demonstrate that at least 50 percent of the population 

targeted has a gross household income that is at or below 185 percent of poverty. 

Although USDA 

Generally 

Incorporates the Key 

Program Design 

Actions Likely to 

Contribute to 

Success, Establishing 

Linkages among 

Programs Is Difficult 

USDA’s Nutrition 

Education Programs 

Identified Target 

Populations and Goals 
Page 20 GAO-04-528 Nutrition Education 

Table 5: USDA’s Nutrition Education Programs Target Similar Populations and Have Overlapping Eligibility Requirements

Program Target population for nutrition education Eligibility for program services 

EFNEP Low-income youth and low-income families with 

children 

There are no specific eligibility requirements, but EFNEP providers 

are encouraged to target EFNEP to families on other types of lowincome assistance, such as food stamps, or to neighborhoods or 

schools with high rates of poverty. 

WIC Low-income pregnant, postpartum, and breastfeeding women; infants; and young children 

receiving WIC 

185% of poverty or less, and assessed as having “nutritional risk”a

Food Stamp 

Program 

Low-income children and families receiving food 

stampsb

130% of poverty or lessb

NSLP School children At or below 130% of poverty for free meals, between 130% and 

185% for reduced price; no restrictions for full-priced mealsc

CACFP 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 

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 centersd

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. 

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 
Page 21 GAO-04-528 Nutrition Education 

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. 

When programs have similar goals and serve similar and potentially 

overlapping target populations, it is important that some mechanisms exist 

that support an array of coordinated activities in order to make the most 

efficient and effective use of resources. On one hand, overlap creates the 

potential for unnecessary duplication of, or gaps in, service delivery as 

well as administrative inefficiencies. On the other hand, overlap between 

agencies or programs that administer similar functions is sometimes 

necessary to meet federal priorities, and in the case of nutrition education, 

participants can benefit from hearing the message from several sources. 

To be effective, the messages across programs must be consistent with 

one another, which requires established linkages across programs. 

USDA recognizes the value of coordinating efforts among these programs; 

in practice, the programs coordinate in various ways. FNS and EFNEP 

staff participate in multiple committees and initiatives within USDA and 

with other federal and nongovernmental organizations to work together on 

specific nutritional issues. For example, officials from USDA and the 

Department of Health and Human Services participate in a working group 

to ensure that dietary guidance from both departments accurately reflects 

the Dietary Guidelines for Americans and the Food Guide Pyramid.21

 

In addition, the programs work with the Food and Nutrition Information 

Center (FNIC) at the National Agricultural Library to provide a forum for 

the exchange of nutrition education information among programs and with 

state and local officials and nutrition educators. However, FNS materials 

 21USDA also participates in committees that work on nutrition education with other federal 

agencies and departments, including the CDC, the National Cancer Institute (NCI), and the 

Departments of Education and Health and Human Services. For example, USDA, CDC, and 

NCI are part of the National 5-A-Day Partnership to formulate national strategies and plans 

to increase the consumption of fruits and vegetables. 

Some Coordinating Efforts 

Exist across Programs 

Providing Nutrition 

Education, but Strong 

Linkages Are Absent 
Page 22 GAO-04-528 Nutrition Education 

are separate from EFNEP’s. FNIC has a memorandum of understanding 

with FSNE, WIC, and Team Nutrition to support their nutrition education 

materials through FNIC’s Web site.22 The Web site houses a wide array of 

nutrition education materials, including multiple databases containing 

nutrition education curricula. For example, the Web site supports the 

Food Stamp Nutrition Connection database, which provides a forum for 

nutrition educators to share curricula, participant materials, and other 

resources with personnel providing nutrition education activities to food 

stamp participants, applicants, and other low-income individuals likely to 

be eligible for FSP. Similarly, the Healthy School Meals Resource System 

provides information to persons working in USDA’s child nutrition 

programs. In addition, FNIC also supports links to discussion groups that 

allow providers of nutrition education to communicate and exchange 

ideas. While there is useful information available through FNIC, we do not 

know the extent to which nutrition educators use these resources. 

Furthermore, FNIC’s Web site does not include either the database of 

nutrition education materials created primarily by EFNEP or a link to this 

database. Instead, CSREES supports the Nutrition Education for Diverse 

Audiences database, which contains nutrition education curricula and 

other related material on its Web site.23 These materials can be a valuable 

resource for those individuals who take advantage of them; however, 

USDA does not systematically ensure coordination or the sharing of 

materials among the programs, particularly between FNS and EFNEP. 

FNS has identified the need to take additional steps to strengthen the 

overall linkages among its programs. For example, as part of the 

department’s strategic goal to promote healthier eating habits and 

lifestyles, it has listed a strategy to support an integrated, cross-program 

nutrition education effort to address health-related problems, such as 

obesity. However, the plan does not describe the specific means, 

mechanism, or responsible authority to implement this strategy. In 

addition, FNS has recognized the need for a more integrated, crossprogram approach in its 1999 report to Congress, the President’s fiscal 

year 2005 budget request, and other documents. For example, in its report 

to Congress,24 FNS states that its goal is to ensure that nutrition education 

 22For more information, see http://www.nal.usda.gov/fnic/databases.html. 

23See http://www.reeusda.gov/f4hn/efnep/necd.htm. 

24U.S. Department of Agriculture, Food and Nutrition Service, Promoting Healthy Eating: 

An Investment in the Future (Alexandria, VA: December 1999), ii. 
Page 23 GAO-04-528 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.25 The funds would support increased coordinating efforts, such 

as the formulation of curricula, the sharing of best practices across FNS 

program participants, and the fostering of collaboration among state 

agencies. 

Despite these initiatives and proposals, overall, we found limited evidence 

of a department-wide unifying strategy to build and support effective 

linkages among the FNS programs and EFNEP that would ensure 

consistency of message, efficient use of resources, and planning for 

service delivery and program development at the federal level. Increasing 

coordination efforts and building strong linkages between EFNEP and 

FNS may be challenging because they are administered by two different 

USDA agencies. For example, we identified missed opportunities to share 

data collection tools and software that could have helped with both 

program efficiency and effectiveness. However, some federal officials we 

spoke with have recognized the need to improve linkages between the two 

USDA agencies. An FNS official said that FNS has begun to focus efforts 

on ways to ensure that nutrition messages are coordinated across its 

programs. However, it has not yet worked with EFNEP on this issue. An 

EFNEP official said that FNS and CSREES are beginning to see the need 

for enhanced coordination and have begun to discuss activities that could 

go in a memorandum of understanding. 

Distinct administrative structures can also create coordination challenges 

and fragmented service delivery at the state level and local level. 

 25The proposed $2.5 million increase would address the lack of funding for cross-program 

initiatives and the widely varying levels of nutrition education within the FNS nutrition 

assistance programs. Of the $2.5 million, $1.5 million would be used to expand the Eat 

Smart, Play Hard nutrition education and promotion campaign and fund the development 

of nutrition promotion materials that could be used in more than one program. The 

remaining $1 million would be used for new projects that operate across FNS program 

boundaries. 
Page 24 GAO-04-528 Nutrition Education 

Specifically, state and local officials are hindered by the different 

administrative structures of each of the programs, including the funding 

streams, personnel, and requirements for designing and delivering 

nutrition education for their target populations. For example, in one state 

we visited, USDA programs were administered by five different agencies, 

ranging from social service and health departments to a Cooperative 

Extension office. Moreover, states often lack a process or a central focal 

point to help coordinate planning efforts among the programs. In our 

report on NSLP, we noted that not all states had established a state focal 

point for leadership or had begun collaboration among state agencies to 

provide nutrition education in schools.26 In the past, the Nutrition 

Education and Training Program helped to fund this central focal point by 

providing the manpower and resources needed for state and local officials 

to coordinate child nutrition programs with nutrition education activities 

in schools and child care centers. Despite the lack of a central focal point, 

we did find instances of local coordination across some programs, but this 

coordination was sporadic and generally involved two programs rather 

than all of them. 

USDA has taken some steps to encourage and facilitate linkages between 

some of its programs that provide nutrition education. At the state level, 

FNS established cooperative agreements with 22 states to establish 

Nutrition Networks, which can act as the collaborative agent at the state 

level to help identify and highlight nutrition problems, such as obesity. 27

Nutrition Networks are state-level organizations that can expand, 

coordinate, and integrate innovative nutrition education messages across 

programs.28 California’s Nutrition Network, for example, includes over 300 

government, nonprofit, and business organizations, including the state 

 26See U.S. General Accounting Office, School Lunch Program: Efforts Needed to Improve 

Nutrition and Encourage Healthy Eating, GAO-03-506 (Washington D.C.: May 9, 2003). In 

this report, we recommended that the Secretaries of Agriculture, Health and Human 

Services, and Education encourage states to identify a focal point in each state to promote 

collaborative efforts that would further develop nutrition education activities for the 

schools.

27In 1995 and 1996, FNS approved cooperative agreements to establish Nutrition Networks 

in 22 states. As of 2002, 19 of the original 22 networks were active and self-sustaining. 

Additional states are creating networks or studying the feasibility of creating networks. 

28Nutrition Networks comprise state and local government agencies, nonprofit 

organizations, and representatives of private industry. The networks use social marketing 

techniques, such as providing nutrition education through public service announcements, 

using mass media to reach food stamp participants, and using researched and tailored 

nutrition education messages. 
Page 25 GAO-04-528 Nutrition Education 

Departments of Health Services, Social Services, Education, and Food and 

Agriculture, and the state’s Cooperative Extension system. State officials 

said that one of the many goals of its network is to identify service gaps 

across nutrition education efforts. USDA also recently began an initiative 

to promote collaboration, known as the State Nutrition Action Plans 

initiative. This initiative encourages state agencies to work together 

toward a more integrated approach to planning and delivering nutrition 

education. When the initiative was launched at its national conference, 

FNS asked state officials to work together to identify goals for 

collaboration and specific objectives and steps to achieve the goals. 

However, the Nutrition Networks are not nationwide, and the State 

Nutrition Actions Plans initiative is still in the early stages of development. 

We found that the USDA programs incorporated the service delivery 

actions likely to contribute to successful nutrition education in different 

ways and to varying extents, but they faced similar challenges that 

affected their ability to fully incorporate these actions. Service delivery 

ranged from one-on-one counseling to broader media campaigns. 

However, challenges such as competing requirements and resource 

constraints limited each program’s ability to fully incorporate all of the 

service delivery actions. 

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 

Programs 

Incorporated the 

Service Delivery 

Actions in Different 

Ways and to Varying 

Extents but Faced 

Similar Challenges to 

Incorporating Them 

EFNEP Incorporated Key 

Service Delivery Actions, 

but Services May Not Have 

Reached Many Eligible 

Participants because of 

Resource Constraints 
Page 26 GAO-04-528 Nutrition Education 

assessment form that determined participants’ fruit and vegetable intake. 

In addition, EFNEP uses paraprofessionals to deliver nutrition education, 

and their presence in these communities may augment their ability to 

assess local needs. An EFNEP official in Michigan, for example, stated that 

having EFNEP paraprofessionals who lived in a Native American 

community enhanced their ability to determine the needs of that 

community. 

The EFNEP program has a core curriculum that includes classes on 

dietary practice, nutrition quality, food safety, food security, and resource 

management. However, EFNEP officials we spoke with stated that the 

program allows educators to tailor parts of the curriculum to address 

participants’ needs. For example, Michigan EFNEP officials told us their 

paraprofessionals developed an individual plan for participants tailored to 

each participant’s responses to questions from the formal needs 

assessment.29 The individual plans included the core curriculum of the 

particular program but also included areas for emphasis or 

supplementation within the curriculum. Similarly, California EFNEP 

introduced a nutrition program into public schools called EatFit. With the 

goal of increasing nutrition and health among school children, the program 

included participant self-assessments, which drove the specific curriculum 

and messages provided through the program’s series of classes. The 

children received tailored interventions, based on the assessments, with 

goals such as increasing fruit intake at lunch and increasing physical 

activity throughout the school day. 

EFNEP officials told us they delivered frequent and ongoing nutrition 

education. Specifically, EFNEP educators provided a series of 

interventions, which varied in number from 6 to 16, generally in the form 

of small group classes over the course of approximately several months to 

a year, depending on the number of interventions.30 EFNEP educators 

provided nutrition education through various sites, such as WIC clinics, 

4-H clubs, community centers, and other key sites in the community. 

Research indicates that providing nutrition education through various 

sites is beneficial to participants. However, officials noted that while the 

delivery of classes over the course of several months helped ensure 

 29This method of service delivery—highly focused on the individual participant—can be 

higher in cost than nutrition education that focuses on broader groups of participants. 

30The core program objectives are set at the national level. However, the number of classes 

offered is at the discretion of the local implementing agency. 
Page 27 GAO-04-528 Nutrition Education 

participants benefited from the services, this benefit could diminish after 

the nutrition education ended. 

A federal program official told us that resource constraints and funding 

formulas presented challenges for equitable service delivery. Given its 

current resources, the program is currently able to fund services in 

approximately 700 to 800 of the nation’s 3,150 counties. This is, in part, 

because EFNEP funding has declined in constant dollars over several 

decades despite a general increase in the number of people eligible for 

EFNEP services. Furthermore, an EFNEP official said the funding formula 

for allocating program resources among states is outdated. It is based on 

census data from the 1960s. As a result, states such as California, where 

the low-income population has increased over the last two decades, had 

less to spend per eligible participant than states with more stable lowincome populations. For example, while California spent roughly 65 cents 

per eligible participant in 2003, South Dakota spent over $5.00 per eligible 

participant.

Some state and local EFNEP providers delivered nutrition education in 

collaboration with other USDA nutrition education programs to broaden 

their reach, according to officials with whom we spoke. For example, in 

Michigan, EFNEP officials told us they leveraged program resources by 

working with the local FSNE initiative to ensure that the geographic areas 

where they provided services did not overlap. 

WIC provides nutrition education services as a part of the program’s 

overall nutrition assistance mission, but officials we spoke with told us 

several competing program requirements and resource constraints limited 

the program’s ability to fully incorporate all of the service delivery actions. 

WIC staff we met with told us their educators, usually nutritionists or 

dieticians, routinely assessed participant needs and usually tailored the 

services to the needs of the WIC population in general.31 However, WIC 

had a limited ability to deliver frequent and ongoing nutrition education. In 

addition, other program requirements restricted the time and resources 

available for nutrition education. 

WIC officials told us that by requiring participants to complete an intake 

form that helped providers identify their nutritional intake and dietary 

 31According to WIC regulations, physicians, registered nurses, physician’s assistants, or 

state or local medically trained health officials may also provide WIC services. 

WIC’s Ability to 

Incorporate the Key 

Service Delivery Actions 

May Have Been Limited by 

Competing Program 

Requirements and 

Resource Constraints 
Page 28 GAO-04-528 Nutrition Education 

behaviors, WIC routinely assessed participants’ needs. WIC providers, 

which included local public and private nonprofit health clinics and 

nonprofit agencies, used these forms to identify high-nutritional-risk 

participants, who, according to federal officials, were slated for more 

intensive, one-on-one nutritional counseling.32 Some WIC providers we 

spoke with also used the intake forms to collect data on the characteristics 

and dietary needs of the program participants overall. Michigan has 

developed a computer system for collecting and tracking participant needs 

that, according to state officials, assisted the state’s local providers in 

knowing what nutrition education services were most needed, the number 

of nutrition education interventions, the number of participants who 

refused WIC nutrition education, and the number of participants enrolled 

in other programs such as Temporary Assistance for Needy Families 

(TANF) and Medicaid. 

Federal WIC officials told us that WIC providers try to tailor nutrition 

education to participant needs when possible, although in most cases, 

participants received nutrition education tailored to the needs of the 

overall WIC population. For example, a Michigan official stated that her 

staff designed nutrition education classes that were appropriate for the 

general WIC community, and participants generally received whatever predesigned class happened to be offered on the day they were in the clinic. 

WIC officials told us that local WIC providers use participant data to help 

tailor services. For example, a Maryland WIC official said the state 

database included several data elements that are helpful in tracking local 

participant health trends, which allowed local clinics to adjust and develop 

their overall curriculum to address the needs of the local participants. 

Several officials stated that given the limited resources and time for WIC 

nutrition education, it was impossible to ensure participants received 

nutrition education that addressed their particular needs except for 

participants at the greatest nutrition risk. 

Federal, state, and local WIC officials we interviewed said the WIC 

program had a limited ability to provide frequent and ongoing nutrition 

education because of competing program requirements. According to 

program rules, WIC providers are required to offer nutrition education to 

participants. However, those who do not attend nutrition education 

activities cannot be denied the other WIC benefits for their lack of 

 32According to FNS officials, state officials have the flexibility to set criteria for their own 

state to determine what conditions constitute high nutritional risk. 
Page 29 GAO-04-528 Nutrition Education 

participation. Moreover, the cost of nutrition education in WIC is a part of 

each local agency’s administrative expenses, which, according to FNS 

officials, forces nutrition education activities to be in competition for 

resources with other administrative requirements and duties.33 For 

example, WIC providers were required by law to provide services 

unrelated to nutrition education, such as voter registration and drug and 

alcohol counseling. Because of these competing demands on time and 

resources, the average WIC participant received approximately less than 

20 minutes of nutrition education twice every 6 months.34 WIC participants 

usually receive WIC services over the course of several years, which 

allows a more sustained participation in nutrition education services, 

according to FNS officials. However, WIC officials in both California and 

Michigan stated that there was little reason to believe such a limited 

exposure to nutrition education would produce meaningful changes in a 

participant’s nutritional knowledge and dietary behavior. 

In response to these challenges, FNS and the states we studied were 

developing technology-driven approaches to nutrition education. FNS, in 

partnership with other organizations, established the WIC Works Resource 

System in January 2000. This Web-based system includes an on-line 

searchable database of materials developed for WIC audiences and 

downloadable materials from the childhood obesity prevention initiative, 

Fit WIC. At the state level, Michigan officials told us they were trying to 

improve access to services by providing some participants with the option 

of receiving services through self-paced Internet classes. In addition, state 

WIC officials have collaborated with other USDA efforts to deliver 

nutrition education. State officials we interviewed cited examples of WIC 

officials working with other programs, such as EFNEP, to develop 

nutrition education curricula, but again time, resources, and other 

program priorities limited their efforts.

 33Although competing requirements limit the time and resources WIC educators are able to 

devote to nutrition education services, FNS officials told us that there is a spending floor 

for nutrition education in WIC, which states cannot go below in providing nutrition 

education services. 

34This is consistent with our prior review of the WIC program. In the study, we reviewed 

the services provided by six local WIC agencies, which were selected using a set of criteria, 

and found the length of time for nutrition education services ranged from 4 minutes to 17 

minutes per intervention. See U.S. General Accounting Office, Food Assistance: WIC Faces 

Challenges in Providing Nutrition Services, GAO 02-142 (Washington, D.C.: December 7,

2001). 
Page 30 GAO-04-528 Nutrition Education 

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 nonEnglish-speaking participants by providing information and giving cooking 

demonstrations in Vietnamese. 

FSNE’s Incorporation of 

the Service Delivery 

Actions Varies Widely, and 

Food Stamp Recipients 

May Not Be Receiving 

FSNE Services 
Page 31 GAO-04-528 Nutrition Education 

FSNE officials in the states we visited told us FSNE services typically 

came through one-time-only interventions. According to FNS officials, a 

series of classes provided through classroom instruction was not the usual 

form of delivery. Services provided via one-time-only methods can include 

media campaigns and other forms of nutrition education designed to reach 

participants through multiple channels. These efforts may incorporate the 

key service delivery actions, when implemented properly. However, 

federal FNS officials told us states’ program plans vary widely in their 

quality and level of detail, and federal FNS officials did not have a clear 

picture of what services local officials provided.35 

FNS officials expressed concerns over the rapid growth in FSNE funding 

in recent years, combined with states’ broad flexibility in implementing the 

program. In particular, from 1992 to 2002, the federal funds dedicated for 

FSNE services have increased, overall, more than for the other programs.36

Moreover, every state FSNE provider has at least one approved waiver to 

allow the provision of nutrition education to non-food stamp recipients, 

according to FNS officials. While this waiver permits states to provide 

services to a wider range of low-income individuals and eliminates the 

administrative burden of checking for Food Stamp Program eligibility, it 

also limits any assurance that Food Stamp Program recipients receive 

FSNE nutrition education. In fact, FNS officials recognized that at the 

state and local level Food Stamp Program officials did not rely on, or 

coordinate with, FSNE efforts or officials in any systematic way. 

FNS officials said they are currently in the process of proposing changes 

to FSNE to address these issues. One of the proposed changes would set 

clear policies and strategies for the delivery of services. This change 

includes developing a policy framework that describes the intended 

structure, target populations, and key behavior changes that FSNE intends 

to promote among participants. This policy framework would also set 

clear roles for the administrators and stakeholders of FSNE services at the 

federal, state, and local levels. In addition to developing this policy 

 35Although FNS has the ability to reject state plans based on noncompliance with federal 

guidelines, FNS officials told us this does not regularly happen. 

36According to officials, state officials may identify noncash resources as a part of the 

state’s match for federal FSNE funds. According to officials, the growth in FSNE funds 

might be due to this ability to identify public noncash matching funds and private cash 

donations, as well as a lack of a cap on the amount of matching funds a state may identify. 
Page 32 GAO-04-528 Nutrition Education 

framework, FNS is developing systems to disseminate resources and 

technical assistance to support state and local FSNE services. 

Because NSLP and CACFP do not have resources or formal systems in 

place to provide nutrition education, program officials rely on Team 

Nutrition to promote and facilitate nutrition education. Unlike the other 

programs, NSLP and CACFP do not fund staff to provide nutrition 

education. Program funds are dedicated to the administration, 

preparation, and delivery of nutritious meals in school and child care 

settings. NSLP food service workers are primarily responsible for the 

preparation and delivery of school meals, and CACFP workers may be 

responsible for providing child care as well as meals in day care settings. 

As a result, FNS relies on Team Nutrition to develop and disseminate 

education materials and provide grants and guidance to states, and Team 

Nutrition is dependent upon the extent to which child care providers and 

school personnel find or make time to devote to nutrition education. 

Team Nutrition, which is supported by staff in FNS headquarters, focuses 

on a broad array of activities intended to build school and community 

support for healthy eating, physical activity, and a healthy school nutrition 

environment.37 By doing this, officials told us they hope to influence the 

complex set of environmental factors in schools that affect children’s 

health and their motivation to change their behavior.38 Team Nutrition 

promotes a nutrition education curriculum that uses multiple 

communication channels to reinforce positive nutrition messages and 

encourage students to make healthy choices. Officials we spoke with 

stated that Team Nutrition materials are of high quality. The nutrition 

education materials are tailored to the broad needs and interests of the 

children at specific age and grade levels. The materials use simple graphics 

to present complex nutrition messages to broad audiences including 

students, parents, and teachers. In addition, Team Nutrition also provides 

grants to schools to support their efforts to create a healthy school 

 37To receive Team Nutrition materials, schools can enroll as a Team Nutrition school by 

affirming their commitment to take the lead in making nutritional changes, conducting 

nutrition education activities and events, and using materials from Team Nutrition. In 

addition, Team Nutrition makes certain materials and resources available to all schools, 

including those that have not enrolled as Team Nutrition schools, on its Web site. 

38For example, in addition to developing nutrition education materials, FNS officials 

reported that federal staff from Team Nutrition and CDC collaborate on an ongoing basis to 

develop materials that address issues such as offering and promoting nutritious food and 

beverage options in vending machines, school stores, and a la carte venues. 

NSLP and CACFP Rely on 

Team Nutrition to 

Incorporate the Key 

Actions, and Its Capacity is 

Limited 
Page 33 GAO-04-528 Nutrition Education 

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. 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. 

 39Also see GAO-03-506. 
Page 34 GAO-04-528 Nutrition Education 

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 of the programs that provide nutrition education did not 

systematically collect data on nutrition education services or recipients at 

the federal level. For example, WIC does not systematically collect data at 

the federal level on the number and characteristics--such as age, gender, or 

income level--of participants receiving nutrition education.40 Nor does it 

collect data on the types of nutrition education provided or the length or 

frequency of nutrition education. Team Nutrition tracks the overall 

numbers of educational materials sent to schools but does not have a 

mechanism for tracking whether and how the materials are used. FSNE 

requires states providing nutrition education to submit some information 

on the number of contacts with people or households and on the services 

provided, but there is wide variation in the types of information provided. 

Moreover, federal officials do not have information about the demographic 

characteristics of FSNE recipients or about whether recipients are also 

food stamp recipients. Nor do they have a system for tracking the 

nationwide frequency of delivery methods such as individual meetings, 

classes, media campaigns, or other means. One FSNE official said that 

while some states may use the EFNEP data-reporting system to collect 

 40While WIC collects data on participants in the overall WIC program, the federal office 

does not have information on the number or characteristics of participants who receive 

nutrition education. 

Programs Generally 

Did Not Incorporate 

Key Nutrition 

Education Evaluation 

Actions, Leaving 

Officials with Limited 

Information about 

Program Results 

Most Programs Did Not 

Systematically Collect 

Data on Nutrition 

Education Services or 

Recipients 
Page 35 GAO-04-528 Nutrition Education 

information, FSNE officials do not know how many states use the system 

and do not receive data collected through the system unless states choose 

to include them in their annual plans. 

However, EFNEP, the one program we reviewed that focuses primarily on 

nutrition education, regularly collected output data on both services and 

recipients. EFNEP gathers a variety of data, including data on the race, 

ethnicity, gender, and family size of recipients; whether nutrition 

education is provided through group or individual instruction; and the 

number of lessons provided.41 The data are collected as part of a 

performance reporting system developed to respond to congressional 

requests for data on program results. To facilitate data collection and to 

produce tailored federal and state reports, the national program office 

provides state and local offices with software to record and analyze client 

data. Although EFNEP does not require states to use the software, almost 

all of the states participating in EFNEP use the software to provide data 

on services and recipients. 

Without systematic data on nutrition education services and recipients in 

each program, federal offices receive inconsistent and incomplete 

information about what or how nutrition education is implemented at the 

local level and who is being served. A 1996 USDA report noted that the 

paucity of data on the department’s nutrition education efforts was an 

obstacle to effective evaluation of those efforts, and one USDA official told 

us that current data collection and monitoring of the nutrition education 

efforts continue to be limited. However, some Team Nutrition officials said 

they were concerned that requiring states to provide detailed data on 

services and recipients would further reduce the limited resources states 

have for providing services and might impose reporting burdens that 

would discourage states from participating in Team Nutrition. 

 41We have not reviewed the quality—including the validity and reliability—of data collected 

by EFNEP. 
Page 36 GAO-04-528 Nutrition Education 

Most of the programs we reviewed did not systematically collect outcome 

data on their nutrition education efforts.42 For example, WIC and Team 

Nutrition did not systematically collect data on changes in the nutrition 

knowledge or dietary behavior of nutrition education recipients.43 While 

most of the programs we reviewed do not require states to provide data on 

potential outcomes of nutrition education, states and localities can choose 

to collect and assess data themselves. But because such data collection is 

optional, most of the programs do not have reliable national outcome data 

in consistent formats. For example, Michigan regularly collects data on 

FSNE participants’ nutrition status before and after receiving nutrition 

education in order to track progress toward goals. But FSNE’s federal 

office does not require such data from participating states and does not 

have consistent nationwide outcome data. 

However, EFNEP programs across the country measured participants’ 

nutrition-related knowledge and dietary behavior through a behavior 

checklist and a 24-hour recall of food consumption administered at 

program entry and exit and reported the data to USDA through their 

common software system. EFNEP annually summarizes the outcome data 

reported by the states, including the extent to which the nutrient intake of 

nutrition education recipients changed after receiving services.44

We have noted in past reports that federal programs that are intended to 

influence the behavior of individuals or that provide grants to states have 

particular difficulty producing outcome measures.45 For example, we have 

 42While outcome data are intended, and generally assumed, to measure the results of 

nutrition education services, they do not necessarily include evidence that the observed 

changes are caused by the nutrition education intervention and not by other external 

factors.

43While WIC collects some data on outcomes of breast-feeding education, it does not 

collect other outcome data on the results of nutrition education. 

44We have not reviewed the validity or reliability of these outcome measurement tools. 

However, one study we reviewed that used EFNEP outcome data noted that the reliance on 

self-reported data may lead respondents to provide socially desirable answers to some 

questions. See Catherine Greenwald Arnold and Jeffery Sobal, “Food Practices and 

Nutrition Knowledge after Graduation from the Expanded Food and Nutrition Education 

Program (EFNEP),” Journal of Nutrition Education, Volume 32, Number 3, May-June 

2000. 

45U.S. General Accounting Office, Grant Programs: Design Features Shape Flexibility, 

Accountability and Performance Information, GAO/GGD-98-137 (Washington, D.C.: June 

22, 1998) and U.S. General Accounting Office, Food Assistance: Performance Measures for 

Assessing Three WIC Services, GAO-01-339 (Washington, D.C.: February 28, 2001). 

Most Programs Did Not 

Systematically Collect 

Outcome Data on Their 

Nutrition Education 

Efforts 
Page 37 GAO-04-528 Nutrition Education 

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 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. 

None of the Programs 

Conducted Regular or 

Nationwide Impact 

Evaluations of the 

Nutrition Education 

Efforts 
Page 38 GAO-04-528 Nutrition Education 

However, the department must balance the resources needed for nutrition 

education research and evaluation with competing demands for research 

on other topics. 

Instead of regularly evaluating the impact of nutrition education efforts, 

the programs conduct occasional studies. Team Nutrition recently 

conducted a nationwide evaluation of a comprehensive nutrition 

education demonstration program for students, but program officials do 

not know if and when a future evaluation will be conducted. Officials 

noted that the study consumed about one-half of the total funding that 

otherwise would have been available for Team Nutrition state grants in 

one fiscal year. In addition, researchers in some states conduct evaluations 

of aspects of the USDA nutrition education efforts, but such evaluations 

are sometimes limited in geographic scope and in their research designs. 

USDA recognizes deficiencies in its current data collection and evaluation 

of nutrition education efforts and has taken steps to improve monitoring 

and evaluation. A 1996 USDA report to the Secretary found that “a 

combination of factors—such as a paucity of data, inadequate funding, and 

a change in expected evaluation outcomes—has created a challenging 

environment for USDA to assess the overall effectiveness of its nutrition 

education activities.”46 In addition, FNS’s 1999 report to Congress stated 

that “the evaluation system for FNS nutrition education is fragmented and 

minimal, and lacks outcome measures.”47 Noting that reliable data and 

evaluation are essential to effective nutrition education planning, FNS 

highlighted the need to establish a system for routine data collection to 

improve nutrition education planning, management, and outcomes, as well 

as ongoing investments in evaluation studies. 

Since then, USDA has begun taking steps to collect more useful data and 

to improve evaluations of program results. Its efforts to improve FSNE 

data collection include a national review of what and how food assistance 

and nutrition services are being provided and the development of a 

uniform data-reporting system for all states participating in FSNE.48 In 

 46U.S. Department of Agriculture, The State of Nutrition Education in USDA: A Report to 

the Secretary (Washington, D.C.: October 1996), ii. 

47Promoting Healthy Eating: An Investment in the Future, ii. 

48According to FNS, data that may be collected under the new Education and 

Administrative Reporting System include demographic characteristics of participants 

receiving nutrition education benefits, information about state goals, topics covered, 

outlets, education strategies, and resource allocations and use. 
Page 39 GAO-04-528 Nutrition Education 

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. 

Despite the lack of regular nationwide evaluations, USDA and others have 

conducted some limited or smaller-scale evaluations and studies of the 

nutrition education efforts.49 We reviewed this research in order to 

determine whether the USDA programs were meeting their nutrition 

education goals (see app. II for the programs’ nutrition education goals). 

However, the research we reviewed is not of sufficient scope and quality 

to allow us to determine whether the programs have met their national 

nutrition education goals, making it difficult for program officials to know 

whether their efforts have been effective.50 We reviewed 20 studies by 

USDA and others conducted over the last 10 years that evaluated nutrition 

education in the USDA programs (see app. I for a description of our 

method for identifying studies and our study review methodology). We 

eliminated five studies with major research design limitations that 

prevented us from concluding that improvements in nutrition knowledge 

or dietary behavior were measured appropriately and were due to the 

nutrition education provided rather than to other factors.51 After 

eliminating the studies with major research design limitations, 15 studies 

 49In addition to identifying several multistate evaluations of USDA nutrition education 

efforts, we identified more limited studies that assessed aspects of the nutrition education 

efforts. 

50In order to assess the extent to which USDA nutrition education efforts were meeting 

their goals, we reviewed research that specifically evaluated the USDA nutrition education 

efforts. In contrast, the key nutrition education actions we describe in figure 2 are based on 

an analysis of research on nutrition education in general. Also, some research has assessed 

the impact of certain nutrition assistance programs. See research cited in GAO-02-142 and 

Phil Gleason and Carol Suitor, Children’s Diets in the Mid-1990s: Dietary Intake and Its 

Relationship with School Meal Participation (Alexandria, Virginia: Mathematica Policy

Research Inc. for the U.S. Department of Agriculture, Food and Nutrition Service, 2001). 

However, these studies did not isolate the impact of nutrition education efforts from the 

overall nutrition assistance programs. 

51Given the methodological challenges of measuring the impact of nutrition education 

services on overall health and well-being, studies we reviewed generally measured the 

impact of these services on nutrition knowledge and behavior. 

Available Research 

Provides Little Information 

about whether the 

Programs Have Met Their 

Nutrition Education Goals 
Page 40 GAO-04-528 Nutrition Education 

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 Studies reviewed 

Studies excluded because of 

major research design 

limitations

Program 

studies

Special 

intervention 

studiesaTotal

EFNEP 10 (2) 7 1 8

FSNE 2 (1) 0 1 1

WIC 7 (2) 2 3 5

Team Nutrition 1 (0) 1 0 1

Total 20 (5) 10 5 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. 

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. 
Page 41 GAO-04-528 Nutrition Education 

Finally, the other 7 studies assessed nutrition education in the nutrition 

assistance programs—NSLP and CACFP (through Team Nutrition),52 WIC, 

and FSNE. However, these studies do not allow us to determine whether 

the programs have met their nutrition education goals because few 

evaluate standard nutrition education efforts and because results were 

sometimes mixed. Four of the studies assessed the impact of special 

interventions or demonstration programs rather than the standard 

nutrition education efforts. Of the remaining studies, none evaluated 

FSNE. And while 1 study of Team Nutrition among fourth-graders found 

modest increases in nutrition knowledge and motivation,53 we did not 

identify any other studies that could help us determine whether Team 

Nutrition had met its program goals. Finally, we identified 2 studies of 

standard WIC nutrition education, but the results of these were mixed. 

One multistate study found that the nutrition education efforts improved 

knowledge and behavior, while another multistate study found that neither 

standard WIC nutrition education efforts nor a special intervention 

improved knowledge among prenatal participants. 

Over the past few decades, the negative health consequences of poor 

nutrition have grown dramatically in the United States. USDA’s nutrition 

education efforts alone cannot be expected to halt the growing rate of 

poor nutrition in the country. However, these efforts could make valuable 

contributions to improving nutrition knowledge and positively influencing 

dietary behaviors among low-income individuals and schoolchildren. 

While only EFNEP is specifically designed to provide nutrition education, 

the other nutrition assistance programs are uniquely positioned to provide 

nutrition education to a broad range of participants. However, USDA faces 

challenges providing nutrition education through these multiple programs 

and incorporating the key actions likely to contribute to success. 

Moreover, USDA has recognized the need for a cross-program integrated 

approach to nutrition education in multiple documents, including its 

recent budget proposal. However, although USDA is taking a number of 

steps to improve the department’s nutrition education activities, it does 

not have an overarching strategy for increasing coordination efforts and 

 52Because CACFP and NSLP provide nutrition education through Team Nutrition, we 

identified studies that evaluated Team Nutrition rather than the two programs. 

53This study assessed Team Nutrition efforts that officials said were more comprehensive 

than but generally representative of Team Nutrition efforts nationwide. 

Conclusions 
Page 42 GAO-04-528 Nutrition Education 

strengthening the linkages across its many nutrition education activities. 

Without strategies for a more unifying approach to designing, delivering, 

and evaluating services across all programs, officials have missed 

opportunities to take advantage of the lessons learned from other nutrition 

education efforts and are less likely to make efficient use of limited 

resources. 

In addition, most of the nutrition education efforts did not fully 

incorporate the monitoring and evaluation actions likely to contribute to 

successful nutrition education. Specifically, USDA lacks reliable data on 

what nutrition education is provided, the outcomes of the services, and 

how they impact nutrition knowledge and dietary behaviors. Properly 

developed outcome measures can provide useful information to program 

officials, given limited resources for larger program evaluations. USDA has 

recognized deficiencies in its current monitoring and evaluation of certain 

nutrition education efforts and is taking preliminary steps to improve 

them. However, the agency has not developed a comprehensive 

agencywide strategy for incorporating the monitoring and evaluation 

actions key to successful nutrition education. Such a unified strategy 

could help the department manage the costs associated with monitoring. 

However, without a strategy to ensure that programs collect reliable data 

on services and recipients, share lessons learned in measuring outcomes, 

and conduct periodic evaluations, officials will have difficulty holding 

programs accountable for meeting their nutrition education goals. Without 

holding programs accountable, USDA officials will be unable to maximize 

the impact of future investments in nutrition education. 

To help overcome the challenges associated with USDA’s nutrition 

education efforts and to help programs incorporate the key actions related 

to successful nutrition education, we recommend that the Secretary of 

Agriculture ensure that the department develop a unifying strategy that, at 

a minimum: 

• Identifies ways to improve coordination efforts and strengthen the 

linkages among the nutrition education efforts, which would include 

examining options ranging from more systematically sharing nutrition 

education resources across programs to identifying and promoting 

approaches for federal, state, and local officials to implement crossprogram strategies to more efficiently use existing resources. In 

developing a unifying strategy, the department may need to submit 

requests for program changes to Congress. 

Recommendations for 

Executive Action 
Page 43 GAO-04-528 Nutrition Education 

• Explores options to collect reliable data on services delivered and 

recipients served, and to identify and disseminate lessons learned. A 

longer-term evaluation strategy could include planning periodic and 

complementary evaluations of the impact of the nutrition education 

efforts to the extent possible, in order to make the most efficient use of 

the resources available for such evaluations. 

We provided a draft of this report to the U.S. Department of Agriculture 

for review and comment. On April 6, 2004, FNS officials, including 

representatives from each FNS program discussed in the report, provided 

us with their oral comments. The officials were in general agreement with 

the recommendations. However, they expressed concern about several 

elements in the draft report. First, they viewed our description of the key 

actions that are likely to contribute to the success of nutrition education 

as too restrictive because it gave the impression that there was only one 

desirable way to provide nutrition education. They pointed out that 

research supports a variety of approaches to providing nutrition 

education. For example, the FSNE program permits both classroom 

activities as well as broader social marketing approaches, which can reach 

more people at a lower cost per person. We agree that various approaches 

can be used to provide nutrition education, as long as the key actions in 

figure 2 are incorporated in some way, and we added language in the 

report in response to this comment. 

Second, FNS officials believed that our description in the draft report of 

the extent to which the programs under review incorporated the key 

actions unfairly held their programs to a standard that was not 

appropriate, given the role of nutrition education in the various programs, 

the variety of appropriate approaches to delivering nutrition education, 

and the current funding levels. We agree that nutrition education plays a 

different role in each of the programs and adjusted our report to better 

reflect that reality and to avoid comparing the programs with one another. 

Third, FNS stated that some of the models for nutrition education are 

much more expensive than others, and we have more fully acknowledged 

this in the report. FNS officials also pointed out that conducting largescale impact evaluations would be a very costly and difficult endeavor. We 

agree with this point and have not recommended that USDA conduct 

numerous large-scale evaluations. Instead, we believe that USDA can more 

carefully develop a longer-term evaluation strategy that includes plans to 

conduct periodic and complementary evaluations of the various programs. 

Agency Comments 
Page 44 GAO-04-528 Nutrition Education 

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. 
Page 45 GAO-04-528 Nutrition Education 

If you or your staff have any questions or wish to discuss this material, 

please call me at (415) 904-2272 or Kay E. Brown at (202) 512-3674. 

David D. Bellis 

Director, Education, Workforce, 

 and Income Security Issues 
Appendix I: Scope and Methodology 

Page 46 GAO-04-528 Nutrition Education 

To identify the key components believed to contribute to successful 

nutrition education, we reviewed key research on the topic, reviewed GAO 

reports and other documents on performance-based management, and 

conducted interviews with experts in the field of nutrition education.1

Specifically, in our review of nutrition education research, we relied 

primarily on one comprehensive research review of 217 nutrition 

education studies at the recommendation of USDA officials and academic 

nutrition education experts.2

 We also relied on additional input of several 

nutrition education experts. Finally, we reviewed GAO reports and other 

documents on performance-based management in order to identify 

program design and evaluation strategies related to successful program 

management.

To answer the questions related to USDA’s nutrition education efforts and 

program planning elements, we conducted interviews with federal officials 

from each of the five USDA programs, examined program reports and 

studies, and reviewed relevant laws and regulations. We also conducted 

interviews with cognizant state and local officials from each of the five 

programs in three states; we conducted site visits in Maryland and 

California and conducted telephone interviews with Michigan officials.We 

selected these states because they represented a range of geographic 

locations and received a range of funding resources for nutrition 

education. Our observations on the delivery of nutrition education are 

primarily based on our site visits and cannot be generalized to the 

programs nationwide. 

To identify recent studies that evaluate nutrition education within the five 

USDA programs we reviewed, we searched relevant databases through 

September 2003, such as Agricola, ABI/Inform, Food Science & 

Technology, Educational Resources Information Center, and National 

Technical Information Service, and reviewed related GAO reports. We also 

spoke with nutrition education experts to identify relevant research.While 

these programs all offer services in addition to nutrition education, our 

report focuses on the nutrition education components of the evaluations.

 1

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. 

2

Contento. We also incorporated information from Dr. Contento’s draft 2004 review of 

nutrition education research. 

Appendix I: Scope and Methodology 
Appendix I: Scope and Methodology 

Page 47 GAO-04-528 Nutrition Education 

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. 3

• 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, 

 3

A substantial number of studies of EFNEP were published prior to 1994. 
Appendix I: Scope and Methodology 

Page 48 GAO-04-528 Nutrition Education 

allowing a comparison of different delivery methods but not an evaluation 

of overall effectiveness.A study of FSNE in Texas used pretest data 

collected retrospectively, at the same time as post-test data, limiting the 

validity of the data.After eliminating the studies with major research 

design limitations, 15 studies remained in our review, as listed in table 7. 
Appendix I: Scope and Methodology 

Page 49 GAO-04-528 Nutrition Education 

Table 7: 15 Studies on Nutrition Education in WIC, FSNE, Team Nutrition (NSLP and CACFP), and EFNEP 

WIC Studies 

Feldman, Robert H. L., Dorothy Damron, Jean Anliker, Michael Ballesteros, Patricia Langenberg, Carlo DiClemente, and Stephen 

Havas. “The Effect of the Maryland WIC 5-A-Day Promotion Program on Participants’ Stages of Change for Fruit and Vegetable 

Consumption.” Health Education & Behavior 27:5 (October 2000):649-663. 

Fox, Mary Kay, Nancy Burstein, Jenny Golay, and Cristofer Price. WIC Nutrition Education Assessment Study: Final Report.

Alexandria, Virginia: Abt Associates Inc. for the U.S. Department of Agriculture, Food and Nutrition Service, 1998.

Havas, Stephen, Jean Anliker, Dorothy Damron, Patricia Langenberg, Michael Ballesteros, and Robert Feldman. “Final Results of the 

Maryland WIC 5-A-Day Promotion Program.” American Journal of Public Health 88:8 (1998): 1161-1167. 

Randall, Bonnie, Kim Sprague, David B. Connell, and Jenny Golay. WIC Nutrition Education Demonstration Study: Child Intervention.

Alexandria, Virginia: Abt Associates Inc. for the U.S. Department of Agriculture, Food and Nutrition Service, 2001. 

Randall, Bonnie, Kim Sprague, David B. Connell, and Jenny Golay. WIC Nutrition Education Demonstration Study: Prenatal 

Intervention. Alexandria, Virginia: Abt Associates Inc. for the U.S. Department of Agriculture, Food and Nutrition Service, 2001. 

FSNE Studies 

Joy, Amy Block, Nancy Feldman, Mary Lavender Fujii, Linda Garcia, Mark Hudes, Rita Mitchell, Sybille Bunch, and Diane Metz. 

“Food Stamp Recipients Eat More Vegetables after Viewing Nutrition Videos.” California Agriculture 53: 5 (September-October 1999): 

24-28. 

Team Nutrition (NSLP AND CACFP) Studies 

The Story of Team Nutrition: Pilot Study Outcome Report. Alexandria, Virginia: Prospect Associates and Westat for the U.S. 

Department of Agriculture, Food and Nutrition Service, 1998. 

EFNEP Studies 

Arnold, Catherine Greenwald, and Jeffery Sobal. “Food Practices and Nutrition Knowledge after Graduation from the Expanded Food

and Nutrition Education Program (EFNEP).” Journal of Nutrition Education 32:3 (May-June 2000): 130-138. 

Brink, Muriel S., and Jeffery Sobal. “Retention of Nutrition Knowledge and Practices among Adult EFNEP Participants.” Journal of 

Nutrition Education 26:2 (March-April 1994): 74-78. 

Burney, Janie, and Betsy Haughton. “EFNEP: A Nutrition Education Program that Demonstrates Cost-Benefit.” Journal of the 

American Dietetic Association 102 (2002): 39-45. 

Cox, Ruby Hurley, Maria Carmen Rita V. Gonzalez-Vigilar, Mary Ann Novascone, and Irma Silva-Barbeau. “Impact of a Cancer 

Intervention on Diet-related Cardiovascular Disease Risks of White and African-American EFNEP Clients.” Journal of Nutrition 

Education 28:4 (July-August 1996): 209-218. 

Dollahite, Jamie, and Michelle Scott-Pierce. “Outcomes of Individual vs. Group Instruction in EFNEP.” Journal of Extension 41:2 (April 

2003). 

Luccia, Barbara H. D., Mary E. Kunkel, and Katherine L. Cason. “Dietary Changes by Expanded Food and Nutrition Education 

Program (EFNEP) Graduates Are Independent of Program Delivery Method.”Journal of Extension 41:3 (June 2003). 

Rajgopal, Radhika, Ruby H. Cox, Michael Lambur, and Edwin C. Lewis.“Cost-Benefit Analysis Indicates the Positive Economic 

Benefits of the Expanded Food and Nutrition Education Program Related to Chronic Disease Prevention.” Journal of Nutrition 

Education and Behavior 34:1 (January-February 2002): 26-37. 

Wessman, Cory, Connie Betterley, and Helen Jensen. “An Evaluation of the Costs and Benefits of Iowa’s Expanded Food and 

Nutrition Education Program (EFNEP): Final Report.”Iowa State University Extension, Ames, Iowa, 2000.

Source: GAO analysis. 
Appendix II: Nutrition Education Goals of 

Key USDA Programs 

Page 50 GAO-04-528 Nutrition Education 

Program Nutrition education goals 

EFNEP To assist low-income families and youths in acquiring the knowledge, skills, attitudes, and changed behavior necessary for 

nutritionally sound diets, and to contribute to their personal development and the improvement of the total family diet and 

nutritional well-being. 

WIC To (1) stress the relationship between proper nutrition and good health with special emphasis on the nutritional needs of 

pregnant, postpartum, and breast-feeding women; infants; and children under 5 years of age; and raise awareness about 

the dangers of using substances during pregnancy and while breast-feeding; and (2) assist the individual who is at 

nutritional risk in achieving a positive change in food habits, resulting in improved nutritional status and in the prevention 

of nutrition-related problems through optimal use of supplemental foods and other nutritious foods.

FSP To provide educational programs that increase, within a limited budget, the likelihood of food stamp recipients making 

healthy food choices and choosing active lifestyles consistent with the most recent advice reflected in the Dietary 

Guidelines for Americans and the Food Guide Pyramid. 

NSLP 

CACFP 

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. 

Source: USDA. 

Appendix II: Nutrition Education Goals of 

Key USDA Programs 
Appendix III: GAO Contacts and Staff 

Acknowledgments 

Page 51 GAO-04-528 Nutrition Education 

Kay E. Brown (202) 512-3674 (brownke@gao.gov) 

Katrina Ryan (415) 904-2114 (ryank@gao.gov) 

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. 

Appendix III: GAO Contacts and Staff 

Acknowledgments 

GAO Contacts 

Staff 

Acknowledgments 

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