Nutrition Education: USDA Actions Needed to Assess Effectiveness, Coordinate Programs, and Leverage Expertise
Released: 2019-07-25T00:00:00

Letter

Background

Administration of USDA’s Nutrition Education Programs

USDA administers its nutrition education programs through multiple agencies in two mission areas—Food, Nutrition, and Consumer Services and Research, Education, and Economics (see fig. 1).

Within the Food, Nutrition, and Consumer Services mission area, FNS oversees nutrition assistance programs with nutrition education components, such as SNAP, WIC, and child nutrition programs. For SNAP-Ed and WIC, the FNS national office develops program policies and guidance and works with the FNS regional offices to provide technical assistance to state agencies. The FNS regional offices also review SNAP-Ed and WIC state plans. The Team Nutrition initiative is administered by FNS national officials who also work on child nutrition programs. FNS staff develop Team Nutrition materials, training resources, and guidance and provide assistance to state agencies and local entities overseeing the child nutrition programs.

Within the Research, Education and Economics mission area, NIFA national officials oversee EFNEP, in part by providing program guidance, reviewing grant recipient plans, and conducting some monitoring and oversight of local implementing entities. The NIFA national office, together with the FNS national office, administers the FINI program. Although NIFA has primary responsibility over the grant award process, FNS has been overseeing an independent evaluation of program efforts.

Interventions for USDA’s nutrition education programs are provided through varied local entities and settings. For example, land-grant universities may provide SNAP-Ed and EFNEP interventions, while local health clinics may provide WIC interventions. USDA’s programs also provide nutrition education in varied settings, ranging from grocery stores to hospitals (see fig. 2). Sometimes multiple nutrition education programs operate in the same setting. For example, SNAP-Ed may provide classes for students while Team Nutrition may distribute teacher training materials and nutrition education curricula to the same school.

Structures, Target Populations, and Types of Education

Most of USDA’s nutrition education programs target interventions to low- income populations with varied characteristics, as shown in table 1, and the programs also differ in how nutrition education fits into their structures. For example, SNAP-Ed and EFNEP are primarily focused on providing nutrition education to participants, while Team Nutrition provides nutrition education to both child nutrition program implementers and participants. WIC provides benefits for food and referrals to health and other social services, as well as nutrition education, including breastfeeding promotion and support, to participants. FINI provides benefits for purchasing healthy foods and may include additional nutrition education programming.

Programs also provide nutrition education through various intervention methods, ranging from direct education, such as cooking demonstrations, classes on healthy eating, and one-on-one counseling, to social media campaigns and efforts to change policies, systems, or environments.

SNAP-Ed provides direct education through a variety of nutrition educators, although its interventions also may involve social marketing and policy, systems, and environmental changes (PSE). PSE is intended to shape policies, practices, and physical environments to support and improve nutrition education, physical activity habits, and obesity prevention efforts. In fiscal year 2018, approximately 76 percent of SNAP-Ed interventions included direct education, whereas 54 percent included PSE, according to USDA data.

EFNEP primarily provides direct education through paraprofessionals, also known as peer educators. Paraprofessionals typically live locally in the community, which allows them to recruit and receive referrals for new participants. University and locally-based professional staff train and supervise the paraprofessionals. In addition, EFNEP has incorporated PSE interventions in recent years. For example, USDA provides PSE training for EFNEP program implementers, as one step toward adopting the PSE approach.

WIC programs also provide direct education, such as counseling and group discussions, and, according to federal regulations, are allowed to use other intervention methods as long as they are easily understood by participants and bear a practical relationship to participant nutritional needs, household situations, and cultural preferences. For example, WIC programs may conduct demonstrations or grocery store tours to help consumers understand how to read nutrition labels or shop on a budget.

Team Nutrition creates and disseminates web-based and hard-copy educational materials to child nutrition program implementers in part to educate child nutrition program participants. For example, Team Nutrition provides curricula, posters, tools, guides, recipes, and cookbooks for schools and child care sites. Team Nutrition also provides annual grants to enhance nutrition education intervention efforts in schools and child care settings, as well as training for program implementers through its partnership with the Institute of Child Nutrition.

FINI supports healthy eating choices by incentivizing the purchase and consumption of fruits and vegetables. For example, some FINI programs provide vouchers redeemable for qualifying fruits and vegetables. Further, according to USDA officials, a FINI program may partner with another USDA nutrition education program, such as SNAP-Ed or EFNEP, to provide nutrition education.

Other USDA Nutrition Education Efforts

USDA agencies also provide nutrition education through other research and guidance directed at the general public:

USDA’s Center for Nutrition Policy and Promotion (CNPP), within FNS, works with the U.S. Department of Health and Human Services to develop the Dietary Guidelines for Americans, dietary guidance linking scientific research to the nutrition needs of consumers. CNPP also takes the lead on consumer nutrition education, including MyPlate, which translates the Dietary Guidelines for Americans for consumers.

USDA’s Economic Research Service (ERS) conducts research and issues publicly available reports related to promoting the purchase and consumption of healthy, economical foods. ERS also provides data relevant to the nutrition of U.S. households and communities.

USDA’s Agricultural Research Service (ARS) serves as a repository for publicly available nutrition education information and data. ARS manages the website Nutrition.gov, the Historical Dietary Guidance Digital Collection, and the FoodData Central data system, which provides food nutrient data for consumers.

USDA Collects Information on Nutrition Education Participation and Expenditures, but Faces Challenges Assessing Effectiveness for One of Its Largest Programs

Information on Participation Includes Those Receiving Direct Education and Other Measures of Program Reach

According to USDA data, 3.8 million and 436,000 people participated in direct education interventions for SNAP-Ed and EFNEP, respectively, in fiscal year 2018. Direct education participation in these two programs, which are focused primarily on nutrition education, has decreased in recent years. Between fiscal years 2010 and 2018, SNAP-Ed direct education participation declined by 33 percent and EFNEP declined by 28 percent. Program officials we spoke with noted some factors that may in part explain these trends. For example, USDA officials said direct education has been less of a focus in SNAP-Ed in recent years, as the department has encouraged programs to use policy, systems, and environmental change interventions and social marketing, in addition to the traditional direct education, following implementation of the Healthy Hunger-Free Kids Act of 2010.

USDA officials said that all WIC recipients are offered nutrition education, and therefore they report that 6.9 million people were offered nutrition education through the program in fiscal year 2018. Although officials consider this to be the best proxy for WIC nutrition education participation, more than 5.2 million of these WIC recipients were infants or children ages 5 and under. In addition, WIC recipients do not need to participate in nutrition education to receive the program’s food benefits. As a result, USDA’s proxy overcounts the number of people who participated in WIC nutrition education.

For Team Nutrition, USDA tracks the reach of its nutrition education using the volume of materials distributed. Between fiscal years 2012 and 2018, Team Nutrition distributed around 5.1 million of its hard-copy materials, such as curricula, technical assistance and training tools, and other materials, to child nutrition program implementers, including schools and day care providers. Further, from March 2014 through fiscal year 2018, there were about 11 million unique views of Team Nutrition materials hosted on USDA’s Team Nutrition website.

Additionally, USDA is collecting participation data for FINI through the FINI National Evaluation. The evaluation is ongoing and FINI participation data will be available after it concludes, according to USDA officials.

USDA Collects Annual National Expenditure Data for All Programs, but Detailed Data Are Limited

USDA’s data show that nearly $907 million was expended on nutrition education programs in fiscal year 2017, the most recent year for which complete data are available, with $826 million expended on two programs—WIC and SNAP-Ed (see fig. 3). Specifically, states expended $422 million on WIC nutrition education and nearly $404 million on SNAP-Ed in that year. Further, grantees expended $51 million on EFNEP, $16 million on Team Nutrition, and $13 million on FINI in fiscal year 2017.

USDA has total annual expenditure data at a national level for its nutrition education programs, but it does not have detailed information on how the funding is expended that can be routinely analyzed in its two programs with the largest expenditures—WIC and SNAP-Ed. Since both programs allow states to use various types of nutrition education interventions, information on spending by type of intervention may help USDA compare costs, and with additional information, potentially assess the cost effectiveness of various nutrition education interventions. For WIC, USDA collected detailed information on nutrition education spending at the local agency level in 2016 through a survey and analyzed the costs associated with different types of nutrition education interventions. In contrast, USDA collects information on SNAP-Ed local implementing agency expenditures in narrative annual reports that make it difficult to assess spending by type of nutrition education intervention.

USDA Has Taken Steps to Evaluate the Effectiveness of its Programs, and Faces Ongoing Challenges Assessing SNAP-Ed

Through studies and data collection, USDA has gathered some information on the effectiveness of its nutrition education interventions. For example, in 2018, USDA completed the WIC Nutrition Education Study, which assessed WIC nutrition education in both descriptive and evaluative ways (see text box). Additionally, USDA officials said a new study is underway looking at how the WIC nutritional risk assessment tailors the benefit package participants receive, including the nutrition education offered. USDA has also funded various grants and cooperative agreements that have evaluated WIC nutrition education to some extent, according to USDA officials.

Findings from WIC Nutrition Education Study: Phase II Report This 2018 study was designed to address research questions about the impact of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)’s nutrition education on participant nutrition and physical activity behaviors, among other things, in six pilot sites.

Although pilot sites’ nutrition education practices varied, the study did not find significant differences in reported exposure to nutrition education, such as the number of contacts with an educator or receipt of materials to reinforce nutrition messages during visits, or significant differences in participant outcome behaviors, among participants by site.

For EFNEP, USDA regularly collects participant data to assess the effectiveness of EFNEP interventions nationwide, and several studies have also assessed the cost effectiveness of EFNEP. Specifically, EFNEP participants take standardized food and physical activity questionnaires and provide information on their dietary consumption in the past 24 hours before and after participating in an intervention, such as a class. EFNEP administrators use this information to measure participant behavior change and also report it to USDA through EFNEP’s data reporting system (see text box). USDA is then able to aggregate these data at the national level and use them to assess the effectiveness of EFNEP interventions nationwide. Further, several studies have evaluated EFNEP cost effectiveness, including one which used national data to estimate EFNEP cost effectiveness by state.

Outcomes Reported on Expanded Food and Nutrition Education Program (EFNEP) Participant Questionnaires Questionnaires are administered when adult EFNEP participants enter the program and again when they exit the program to measure behavior change in core areas, including diet quality and physical activity, food safety, food resource management, and food security. For fiscal year 2018, the majority of participants reported improvements in diet quality (92 percent), food resource management (80 percent), food safety (79 percent), and physical activity (78 percent). Further, almost half of participants reported improvement in food security (47 percent).

In addition to WIC and EFNEP, USDA is currently collecting information from its grantees on FINI effectiveness as part of its forthcoming FINI National Evaluation. An interim evaluation report found a positive, but modest, impact of FINI on monthly household fruit and vegetable expenditures, but no measurable impact on adults’ daily fruit and vegetable consumption. Previously, USDA assessed the effectiveness of the Healthy Incentives Pilot, which was a predecessor to FINI. The pilot tested the impact of making fruits and vegetables more affordable for SNAP participants and found that participants consumed almost one- quarter of a cup more fruits and vegetables per day than non- participants.

USDA has also taken steps to support evaluation of the effectiveness of SNAP-Ed interventions both through its own research and the development of an evaluation framework. In 2012 and 2013, USDA reviewed selected SNAP-Ed interventions to identify potential models of effective SNAP-Ed interventions and impact evaluations. Specifically, USDA evaluated five interventions aimed at increasing fruit and vegetable consumption in preschool or elementary-age children, one intervention aimed at increasing fruit and vegetable consumption in low-income seniors, and one intervention aimed at increasing low-income women’s knowledge of healthy eating choices. Also in 2013, the FNS Western Regional Office began an effort to develop the SNAP-Ed Evaluation Framework (Framework), which was finalized in 2016 and fully adopted for national use. The Framework was developed as a way to evaluate program interventions, and with the intention of encouraging use of policy, systems, and environmental change interventions, according to USDA officials.

All states are currently using the Framework to evaluate SNAP-Ed program interventions, according to USDA officials; however, because the Framework allows for myriad ways to measure outcomes, information reported by states on the effectiveness of SNAP-Ed interventions varies widely. Within states, SNAP-Ed implementing entities can select from 51 indicators and various outcome measures in the Framework to evaluate their interventions. Although USDA has identified 7 of the Framework’s 51 indicators as priority indicators, and encouraged states to use these, each indicator has multiple outcome measures and data collection methods associated with it (see text box). Therefore, even if the same indicators are selected to evaluate the effectiveness of different SNAP-Ed interventions, each state may select different outcome measures and data collection methods, and report different information on effectiveness. In our prior work, we found that agencies that seek to manage an excessive number of performance measures may risk creating a confusing excess of data that will obscure rather than clarify performance issues.

Elements of a Selected Medium Term Change Indicator: Healthy Eating The medium term change indicator for healthy eating acts as a priority indicator among the 51 indicators included in the Supplemental Nutrition Assistance Program Education (SNAP-Ed) Evaluation Framework. SNAP-Ed programs may use this indicator to measure healthy eating behavioral changes reported by SNAP-Ed participants before and after participation in a series of direct nutrition education classes. Within this indicator, programs may select from various outcome measures and data collection tools:

Programs may select from 13 outcome measures to assess the participants on this indicator. Some options include eating more than one kind of vegetable, drinking water, and using MyPlate to make food choices.

To assess these outcome measures, programs may select from 11 surveys and other data collection tools compiled by the U.S. Department of Agriculture, such as a food behavior checklist for adults and a beverage and snack questionnaire for older youth.

In addition, USDA receives information on states’ evaluations of effectiveness that is not easily analyzed nationwide. Although states report information on SNAP-Ed interventions to USDA in a data system, including information on participation, demographic characteristics of direct education participants, and types of education interventions, the data system is not structured to allow states to report information on intervention effectiveness, including cost effectiveness. Instead, USDA uses SNAP-Ed state plans and annual reports to collect information on state efforts to evaluate program effectiveness, among other things. However, in their plans and reports, states identify the Framework indicators they use and describe their evaluation efforts and outcomes in narrative form, limiting USDA’s ability to aggregate evaluation information across states or interventions, according to USDA officials. One local SNAP-Ed official said her state’s most recent annual report was approximately 60 pages long, highlighting the magnitude of the narrative information some states provide. While USDA officials acknowledged these challenges, they said a narrative report is used to accommodate the differences among SNAP-Ed programs.

USDA officials said that because the Framework is still relatively new, they are working to determine both how to assist states’ efforts to use it to evaluate SNAP-Ed effectiveness and to ensure these evaluations provide USDA with useful information for assessing these programs. Further, USDA officials said they are currently in the process of determining future SNAP-Ed reporting protocols to improve program implementation and impact. Federal internal control standards state that agencies should use relevant, quality information from reliable sources to inform decision- making and evaluate performance in achieving key objectives. Without information that can be compared across states or easily aggregated or reviewed nationwide, USDA is unable to assess the effectiveness of interventions used across the country to determine whether SNAP-Ed is achieving program goals.

USDA Lacks a Formal Coordination Mechanism and Does Not Fully Leverage Internal Expertise for Its Nutrition Education Efforts

Coordination of Nutrition Education Efforts Is Limited

USDA’s national office does not have a formal coordination mechanism for department-wide nutrition education efforts; however, the department has taken some steps to coordinate efforts related to nutrition. For example, USDA convened staff from various program offices in November 2017 for a two-day Intra-Departmental Nutrition Workgroup Meeting. The focus of the meeting was not specifically nutrition education, but included a discussion of current and potential USDA efforts to encourage healthy food choices for certain age groups. The department also has a few committees that address nutrition issues, including the Human Nutrition Coordinating Committee and the Interagency Committee on Human Nutrition Research. Although these committees do not focus on nutrition education, they convene USDA officials and other federal partners on a regular basis. Despite the lack of a focus on nutrition education in these meetings, USDA officials who participated said these opportunities were useful for sharing related information with staff from across the department.

USDA has also taken some steps to coordinate efforts across nutrition education programs that have an intersection of target populations, though this has not consistently occurred at the federal level, according to USDA officials. For example, in recent years, WIC officials collaborated with Team Nutrition officials on the development of infant feeding and breastfeeding resources for use in child care settings to ensure consistent messaging. However, USDA officials reported that other programs with similar target populations have not coordinated. For example:

USDA officials told us WIC and SNAP-Ed officials have limited interaction, although both programs serve low-income families with young children and coordination could help reinforce key messaging from each program.

Several regional SNAP-Ed officials said that they had limited involvement with Team Nutrition, although both programs may serve students in schools and sharing resources could help maximize program impact.

Both SNAP-Ed and EFNEP focus on providing nutrition education to similar populations and are delivered by land-grant universities, yet there is limited coordination between the two programs. Regional officials who work on SNAP-Ed reported limited familiarity with EFNEP and said they have learned about EFNEP efforts intermittently through state and local officials, rather than from the national office. Similarly, representatives of the two land-grant universities we spoke with who solely administer EFNEP had limited information regarding SNAP-Ed efforts, though they expressed interest in coordinating efforts to maximize both programs’ reach and avoid duplication of effort.

In the absence of formal coordination mechanisms from USDA headquarters, other efforts have developed to help coordinate nutrition education programs nationwide, though USDA national office involvement is limited.

Association of SNAP Nutrition Education Administrators: Representatives of SNAP-Ed state implementing agencies formed the Association because they lacked a mechanism to communicate with FNS national office staff or one another on topics related to nutrition education, according to a representative of this group. Officials from FNS’s national and regional offices formally participate in the group’s annual conferences and other activities, but this representative told us that members of the group would appreciate more opportunities to interact directly with these officials.

SNAP-Ed Program Development Group: Land-grant universities established this separate SNAP-Ed-focused workgroup to strengthen SNAP-Ed programs and nutrition networks at the state, regional, and national levels, and identify linkages between SNAP-Ed and the land- grant university system’s broader outreach, education, and research mission. SNAP-Ed officials from FNS’s national office do not regularly participate in this group, yet the NIFA administrator of EFNEP sits on the group’s leadership committee.

Food, Nutrition, and Consumer Services Nutrition Council: This group convenes national and regional staff in the Food, Nutrition, and Consumer Services mission area on nutrition-related topics and is currently led by regional officials, although the group was previously led by both national and regional officials. FNS officials told us the Nutrition Council has not regained momentum at the national office level since leadership transitioned to the regional office level, and one regional official with leadership responsibilities on the Council told us the group would benefit from more leadership support from FNS national office staff.

State Nutrition Action Councils (SNACs): At the state level, SNACs are primarily comprised of state representatives from FNS programs and develop statewide cross-program nutrition education plans. FNS’s national office has supported SNACs as a model for coalescing state programs around nutrition education and obesity prevention efforts but has delegated leadership of the SNACs to the regions, who work directly with state agencies.

USDA does not have a dedicated individual or entity with leadership responsibility for nutrition education, and program staff who work on nutrition education are currently focused on their individual programs, according to USDA officials. Although FNS has a senior nutrition advisor who supports national and regional officials who work on FNS programs, the advisor’s role does not encompass department-wide coordination on nutrition education. Further, program staff whose responsibilities include nutrition education serve the needs of their individual programs and lack formal communication channels with one another, according to USDA officials. Previously, from 1998 through 2008, USDA had a centralized Nutrition Services Staff that served as a formal coordinating entity for FNS and held cross-program nutrition education meetings, which were useful for information sharing, according to USDA officials. In 2008, this division, which had been comprised largely of nutritionists, was dissolved, with its staff with nutrition expertise largely dispersed to individual program offices.

According to national and regional officials, in recent years, coordinating nutrition education has not been a priority for USDA, and there has been a loss of staff resources dedicated to nutrition education in the department overall. National and regional officials said it is hard to find time to coordinate across nutrition education efforts because they face competing priorities and increased workloads, at times because staff with nutrition education expertise have left employment with USDA and not been replaced. According to regional officials, a voluntary group of FNS national and regional officials who meet to discuss nutrition issues has experienced diminishing participation in recent years, in part due to these reasons.

Regional officials and land-grant university officials said that more formal coordination mechanisms to provide leadership and promote cross- department coordination and information sharing on nutrition education could help increase efficiency, maximize the use of federal resources, and avoid potential duplication of effort. One regional official said she regularly reaches out to a colleague to obtain information on other FNS nutrition education programs, but a centralized tool could provide this information quicker and more efficiently. Another regional official said she compiled information on USDA nutrition education grant opportunities for states in her region, but it would be helpful if this information were centrally compiled by the national office. Regional officials and land- grant university officials we spoke with also said formal collaboration mechanisms, such as a document or tool with information on all of USDA’s nutrition education efforts, examples of best practices for coordination, or an annual meeting to encourage information sharing, would be useful.

Federal internal control standards state that agencies should communicate quality information across reporting lines to enable personnel to perform key roles in achieving objectives, and management should set the tone at the top and throughout the agency to ensure priorities are understood by all stakeholders. In our prior work, we reported that effective coordination can help reduce overlap and duplication, and we found that sustained leadership is an essential element to developing collaborative working relationships. We also identified leading practices that federal agencies can use to enhance the effectiveness of their collaborative efforts, such as agreeing on roles and responsibilities and establishing policies and procedures to work across organizational boundaries.

USDA has acknowledged the importance of nutrition education coordination for maximizing the reach and potential impact of federal nutrition education and nutrition assistance programs in some of its program regulations and guidance, and this emphasis is consistent with new federal requirements. For example, FNS’s SNAP-Ed plan guidance directs states to coordinate SNAP-Ed activities with other national, state, and local nutrition education, obesity prevention, and health promotion initiatives and interventions, such as WIC and EFNEP. In our 2004 review of USDA’s nutrition education efforts, we found that increased coordination, such as sharing curricula, lessons learned, and data collection tools across efforts, could help USDA’s nutrition education programs make more efficient and effective use of resources. Consistent with this focus, the Agriculture Improvement Act of 2018 (Farm Bill) requires USDA to submit an annual report to Congress that includes an evaluation of the level of coordination between SNAP-Ed, EFNEP, and other USDA nutrition education programs.

USDA Has Not Fully Leveraged Its Expertise for Nutrition Education

Some USDA nutrition experts are in agencies disconnected from the nutrition education programs (see fig. 4), yet these agencies play a significant role in developing and compiling dietary guidance, research, and other information related to nutrition education (see table 2).

Despite their role in developing and compiling research and information related to nutrition education, consultation with these experts by the program offices is limited, according to USDA officials, possibly because they are located in separate agencies. For example,

Although CNPP leads a cross-cutting committee that reviews nutrition education materials developed by USDA program staff to ensure materials are consistent with the Dietary Guidelines for Americans,CNPP officials noted they have been infrequently consulted by program officials while materials are under development or activities are being implemented. This may have been in part related to organizational structure, as until recently CNPP and FNS were separate agencies that individually reported to the Office of the Under Secretary for Food, Nutrition, and Consumer Services, according to USDA officials. Some nutrition education program staff also told us they currently use the core nutrition messages on USDA’s website when developing nutrition education materials—messages that CNPP officials noted were developed in 2010 and have not been updated to reflect the latest edition of the Dietary Guidelines for Americans. This approach may lead to inefficiencies in the development of nutrition education materials.

Although ERS conducts nutrition research, nutrition education program officials were not always aware of or using ERS resources, possibly because most of the programs reside in a different USDA mission area. A prior working group attempted to bridge the organizational divide between ERS and some of USDA’s other agencies and offices that work on nutrition education by assisting efforts to share information, but the group has since dissolved. Currently, some national and regional officials we spoke with who work on nutrition education programs had limited awareness of ERS’s nutrition education research. For example, some program officials in the national office were unsure whether ERS did work related to nutrition education and learned of ERS research through automated email updates. Further, one regional official learned of ERS data on food insecurity, which can help states meet federal requirements for targeting nutrition education services to local areas based on their level of need, through a meeting with an outside agency.

Nutrition education program officials were also generally unaware of ARS’s efforts related to nutrition education. Specifically, USDA nutrition education program officials we spoke to said they had little direct contact with ARS officials and were generally unaware of ARS efforts related to nutrition education. Further, regional officials who work on SNAP-Ed had not used or distributed ARS resources to state officials and also seemed generally unaware of ARS’s nutrition education efforts.

USDA lacks a mechanism for systematically integrating its internal nutrition expertise into its nutrition education programs, which may inhibit the effectiveness of the department’s efforts. Federal internal control standards state that agencies should use quality information from reliable internal sources, among others, to inform decision-making. Further, in our prior work, we found that identifying and addressing needs by leveraging resources is a leading practice for collaboration. Nutrition education program officials are missing opportunities to benefit from relevant expertise within USDA but outside their program offices. Failing to leverage its own internal expertise hinders USDA’s development of nutrition education materials that are informed by the latest nutrition guidance and research.

Conclusions

Poor nutrition contributes to costly chronic diseases that are among the leading causes of death for Americans, and USDA’s nutrition education programs and related efforts strive to educate Americans on nutrition and improve their dietary choices. Because USDA’s nutrition education programs are primarily targeted to low-income adults and children, who may receive federally-funded nutrition assistance benefits, these programs also have the potential to improve the likelihood that recipients will spend those benefits to obtain foods that have a positive impact on their health. However, in order to reach these goals, USDA needs to ensure that its programs are effectively educating participants to maximize the impact of the federal investment in nutrition education. Although USDA has some information on the effectiveness of its nutrition programs, without improvements to how USDA gathers information on the effectiveness of SNAP-Ed interventions nationwide, USDA will be unable to ensure one of its largest investments in nutrition education is meeting its goals.

The 2018 Farm Bill included a requirement for USDA to begin reporting annually on the level of coordination between its nutrition education programs, and USDA has acknowledged the importance of coordination and information sharing to maximize nutrition education programs’ impacts. However, the department currently lacks a formal mechanism to ensure this occurs. As a result, USDA risks missing opportunities to increase efficiency, maximize the use of federal resources, and avoid potential duplication of effort. In addition, without coordination between nutrition education program officials and others with nutrition expertise in the department, programs will develop nutrition education materials that fail to fully leverage the latest nutrition guidance and research, possibly missing opportunities to effectively influence the dietary choices of their target populations in the process.

Recommendations for Executive Action

We are making the following three recommendations to USDA: 1. The Administrator of FNS should improve how FNS gathers information on the effectiveness of SNAP-Ed interventions, in order to ensure that these interventions are meeting program goals. (Recommendation 1) 2. The Secretary of Agriculture should direct the Under Secretaries for Food, Nutrition, and Consumer Services and for Research, Education, and Economics to develop a formal mechanism, such as a designated individual or group of individuals, for providing cross-department leadership for USDA’s nutrition education efforts and facilitating cross- program information sharing. (Recommendation 2) 3. The Secretary of Agriculture should direct the Under Secretaries for Food, Nutrition, and Consumer Services and for Research, Education, and Economics to identify and implement mechanisms to fully leverage the department’s nutrition expertise for its nutrition education efforts. (Recommendation 3)

Agency Comments

We provided a draft of this report to USDA for review and comment. In its comments, reproduced in appendix II, USDA generally agreed with our recommendations. USDA also noted that FNS has efforts underway to comply with the 2018 Farm Bill requirement that the department report annually on the level of coordination between its nutrition education programs. USDA also provided technical comments, which we incorporated as appropriate.

We are sending copies of this report to the Secretary of Agriculture, congressional committees, and other interested parties. In addition, this report will be available at no charge on the GAO website at https://www.gao.gov.

If you or your staff have any questions about this report, please contact me at (202) 512-7215 or larink@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix III.

Appendix I: Objectives, Scope, and Methodology

Our report examines the extent to which the U.S. Department of Agriculture (USDA) (1) has information on participation, expenditures, and effectiveness for its nutrition education programs; and (2) coordinates its nutrition education efforts and leverages internal nutrition expertise for these efforts. The scope of our review includes five federal programs that provide nutrition education: Supplemental Nutrition Assistance Program Education (SNAP-Ed), the Expanded Food and Nutrition Education Program (EFNEP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Team Nutrition, and the Food Insecurity Nutrition Incentive (FINI) Grant Program. Among USDA programs that provide nutrition education, four of these received the greatest amount of federal funding for nutrition education in fiscal year 2018—WIC, SNAP-Ed, EFNEP, and Team Nutrition. In addition, we included FINI because it is a grant program in which nutrition education can be a component, and the program’s goal is to incentivize healthy eating. We also reviewed USDA efforts that provide nutrition education through nutrition-related research and guidance directed at the general public.

In addition to the methods discussed below, to address both of our research objectives, we reviewed relevant federal laws, regulations, and guidance, as well as our prior work on USDA nutrition education efforts and leading practices for collaboration. We interviewed officials from relevant USDA agencies, including the Food and Nutrition Service (FNS) and the National Institute of Food and Agriculture (NIFA), which oversee the nutrition education programs described in this report. We also interviewed officials from other USDA agencies overseeing nutrition- related research and guidance, including the Agricultural Research Service, the Center for Nutrition Policy and Promotion, and the Economic Research Service. Additionally, we interviewed officials from the seven FNS regional offices, including officials who work on SNAP-Ed and the Child and Adult Care Food Program. We also interviewed representatives of selected organizations knowledgeable about USDA’s nutrition education efforts. We assessed USDA’s efforts to collect information on its nutrition education programs, coordinate its nutrition education efforts, and leverage internal nutrition expertise against GAO’s standards for internal controls in the federal government.

Participation Data

To address the first objective, we analyzed USDA data on nutrition education participation. Two of the nutrition education programs, SNAP- Ed and EFNEP, collect data on direct education participation. We analyzed SNAP-Ed total direct education participation data for fiscal years 2010 through 2018 collected through SNAP-Ed’s data reporting system, the Education and Administrative Reporting System (EARS). We analyzed EFNEP total direct education participation data for fiscal years 2010 through 2018. These data are reported through the Web-based Nutrition Education, Evaluation and Reporting System (WebNEERS), an integrated data collection system, sponsored by NIFA, and used at the county, state, and federal levels. To assess the reliability of the SNAP-Ed and EFNEP participation data, we interviewed FNS and NIFA officials and reviewed relevant documentation. We determined that these data were sufficiently reliable for the purpose of reporting the number of direct education participants in SNAP-Ed and EFNEP.

We also reviewed available USDA data on the number of people reached by nutrition education efforts in SNAP-Ed and EFNEP other than through direct participation. SNAP-Ed collects information on the number of people reached by nutrition education efforts that are not direct education, such as policy, systems, and environmental change interventions and social marketing. However, states face challenges with tracking individuals reached by these education interventions, and these data are likely to include duplicate records of individuals, according to USDA officials. Therefore, we concluded that these data were not sufficiently reliable for the purpose of reporting the number of people indirectly reached by SNAP-Ed. EFNEP also collects information on indirect education reach. This information tracks other family members of adults who participated in direct education who therefore may also benefit from the information shared, according to USDA officials. To assess the reliability of these data, we interviewed NIFA officials and reviewed relevant documentation. We determined that these data were sufficiently reliable for the purpose of describing the number of people indirectly reached by EFNEP.

Because USDA officials consider the total number of WIC participants to be the best proxy for WIC nutrition education participation, as all WIC participants are offered nutrition education, we analyzed WIC total participation, and participation by women, infants, and children, for fiscal years 2010 through 2018. These data are reported on the FNS- 798/798A Financial Management and Participation Report form, which contains programmatic and financial data reported by state agencies, Indian Tribal Organizations, and U.S. territories through the Food Programs Reporting System (FPRS). To assess the reliability of these data, we interviewed FNS officials and reviewed relevant documentation. We determined that these data were sufficiently reliable for reporting the number of WIC participants offered WIC nutrition education.

Data were unavailable on participation for Team Nutrition—a program which provides training and technical assistance to child nutrition program operators, and creates and disseminates materials for child nutrition program participants. As a proxy measure for program reach, we analyzed data on nutrition education materials disseminated to participants and the online views and downloads of nutrition education materials. To assess the reliability of these data, we interviewed FNS officials and reviewed relevant documentation. We determined that these data were sufficiently reliable for the purpose of reporting the number of Team Nutrition materials disseminated.

Expenditure Data

To address the first objective, we also analyzed WIC, SNAP-Ed, EFNEP, Team Nutrition, and FINI total nutrition education expenditure data for fiscal year 2017, the most complete data available as of April 2019. Like WIC participation data, WIC expenditure data are reported on the FNS- 798/798A Financial Management and Participation Report form through FPRS. Federal SNAP-Ed and Team Nutrition expenditure data are reported on the SF-425 form, which state agencies submit quarterly, also through FPRS. USDA tracks nationwide expenditures for EFNEP and FINI through NIFA’s payment system, Automated Standard Application for Payments; grants management system, Cooperative Research, Education, and Extension Management; and financial management system, Financial Management Modernization Initiative. To assess the reliability of these data, we interviewed officials from FNS and NIFA and reviewed relevant documentation. We determined that these data were sufficiently reliable for the purpose of reporting nationwide expenditures for these five programs.

Program Evaluations and Additional Program Data

To determine what information USDA has on the effectiveness of its nutrition education programs, we reviewed relevant program evaluations from USDA issued within the last 10 years. We selected these evaluations based on information we obtained from USDA and other knowledgeable officials through interviews and relevant documents.

To provide additional context on program operations for SNAP-Ed and EFNEP, we reviewed various program data. We analyzed the EARS data on the total number of SNAP-Ed implementing agencies, including the number of land-grant universities that were implementing agencies, and the types of education provided by SNAP-Ed programs in fiscal year 2018. For EFNEP, we reviewed data on participant outcomes, reported through WebNEERS, for fiscal year 2018. To assess the reliability of these data, we interviewed officials from FNS and NIFA and reviewed relevant documentation. We determined that these data were sufficiently reliable for the purpose of our reporting objectives.

Interviews with Land-Grant University Representatives

To gain the perspective of officials involved in the implementation of nutrition education efforts, we interviewed representatives of four land- grant universities. Land-grant universities are the sole provider of EFNEP and one of the main providers of SNAP-Ed. We judgmentally selected a non-generalizable sample of four land-grant universities based on various criteria, including the recommendations of knowledgeable officials, geographic dispersion, and other factors, such as the percentage of the university’s state population in poverty. Two of the universities we selected solely administer EFNEP and two administer both EFNEP and SNAP-Ed. We gathered information from these land-grant university representatives on how they provide nutrition education through their programs and the extent to which they coordinate with other SNAP-Ed programs in their county and state, as well as with other USDA nutrition education programs. We also gathered information on support they receive from the USDA national office for coordination, if any; their perspectives on challenges USDA faces to coordinating nutrition education across its programs, if any; and their views on opportunities for USDA to improve coordination across nutrition education programs. Information collected from the land-grant university representatives cannot be generalized to all land-grant universities nationwide.

We conducted this performance audit from December 2018 to July 2019 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Appendix II: Comments from the U.S. Department of Agriculture

Appendix III: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the contact named above, Rachel Frisk (Assistant Director), Kristen Jones (Analyst-in-Charge), and Sara Rizik made key contributions to this report. Also contributing to this report were Monika Gomez, Stacy Ouellette, Almeta Spencer, Rachel Stoiko, Curtia Taylor, Walter Vance, Sarah Veale, and Adam Wendel.