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Report to the Committee on Agriculture, Nutrition, and Forestry:

U.S. Senate:

United States General Accounting Office:

GAO:

April 2004:

Nutrition Education:

USDA Provides Services through Multiple Programs, but Stronger Linkages 
among Efforts Are Needed:

GAO-04-528:

GAO Highlights:

Highlights of GAO-04-528, a report to the Committee on Agriculture, 
Nutrition, and Forestry, U.S. Senate 

Why GAO Did This Study:

The Centers for Disease Control and Prevention recently reported that 
poor nutrition and lack of physical activity are catching up to 
tobacco use as the leading cause of death in the United States. In 
addition to having negative health outcomes, children with poor 
nutrition may have a harder time succeeding in school than other 
children. To help improve nutrition, the U.S. Department of 
Agriculture (USDA) provides nutrition education through five of its 
programs. The department spent $472 million on these efforts in fiscal 
year 2002. 

GAO was asked: (1) What key actions can officials take to increase the 
likelihood of success in nutrition education? (2) Do USDA and state 
and local officials take these actions during program design, service 
delivery, and program monitoring and evaluation?

What GAO Found:

GAO identified several key actions, based on research and performance-
based management principles, that increase the likelihood that 
programs providing nutrition education will achieve their goals. As 
the figure below shows, examples of these actions include identifying 
program goals, tailoring services to meet the needs of participants, 
and collecting data on program results. The actions can be taken 
during program design, service delivery, and program monitoring and 
evaluation. 

Key Actions That Increase the Likelihood of Successful Nutrition 
Education: 

[See PDF for image]

[End of figure]

USDA programs providing nutrition education that we reviewed—the Food 
Stamps Program; the Special Supplemental Nutrition Program for Women, 
Infants, and Children (WIC); the National School Lunch Program; the 
Child and Adult Care Food Program; and the Expanded Food and Nutrition 
Education Program—generally incorporated the key program design 
actions likely to contribute to success. For example, the USDA 
programs identified nutrition education goals and target populations. 
However, the programs’ administrative structures hinder coordination 
among the USDA nutrition education efforts.

We found that the USDA programs incorporated the service delivery 
actions likely to contribute to successful nutrition education in 
different ways and to varying extents, but they faced similar 
challenges that affected their ability to fully incorporate these 
actions. The challenges included limited resources and systems for 
providing nutrition education and competing program requirements that 
took time or resources away from nutrition education. For example, WIC 
officials said they had limited time for nutrition education because 
of competing requirements, such as providing information on drug and 
alcohol counseling.

USDA’s nutrition education efforts did not fully incorporate the 
monitoring and evaluation actions that contribute to success, such as 
collecting data on the types of nutrition education provided and the 
outcomes of the efforts. As a result, little is known about what 
nutrition education is provided and whether these programs have met 
their nutrition education goals.

What GAO Recommends:

GAO recommends that the Secretary of Agriculture develop a unifying 
strategy for USDA’s nutrition education efforts that (1) identifies 
ways to improve coordination efforts and strengthen the linkages among 
the nutrition education efforts and (2) explores options to improve 
program monitoring and evaluation by collecting reliable data on 
services and recipients, identifying and disseminating lessons 
learned, and considering a longer-term evaluation strategy.

www.gao.gov/cgi-bin/getrpt?GAO-04-528.

To view the full product, including the scope and methodology, click 
on the link above. For more information, contact David Bellis at (415) 
904-2272 or bellisd@gao.gov.

[End of section]

Contents:

Letter:

Results in Brief:

Background:

Several Actions Are Key to Performance-Based Management and Successful 
Nutrition Education:

Although USDA Generally Incorporates the Key Program Design Actions 
Likely to Contribute to Success, Establishing Linkages among Programs 
Is Difficult:

Programs Incorporated the Service Delivery Actions in Different Ways 
and to Varying Extents but Faced Similar Challenges to Incorporating 
Them:

Programs Generally Did Not Incorporate Key Nutrition Education 
Evaluation Actions, Leaving Officials with Limited Information about 
Program Results:

Conclusions:

Recommendations for Executive Action:

Agency Comments:

Appendix I: Scope and Methodology:

Appendix II: Nutrition Education Goals of Key USDA Programs:

Appendix III: GAO Contacts and Staff Acknowledgments:

GAO Contacts:

Staff Acknowledgments:

Tables:

Table 1: Characteristics of EFNEP:

Table 2: Characteristics of WIC:

Table 3: Characteristics of FSP:

Table 4: Characteristics of NSLP and CACFP:

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

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

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

Figures:

Figure 1: USDA Nutrition Education Expenditures Have Increased Overall 
between Fiscal Years 1992 and 2002:

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

Abbreviations:

CACFP: Child and Adult Care Food Program:

CSREES: Cooperative State Research, Education, and Extension Service:

EFNEP: Expanded Food and Nutrition Education Program:

FNS: Food and Nutrition Service:

FSNE: Food Stamp Nutrition Education:

FSP: Food Stamp Program:

NSLP: National School Lunch Program:

TANF: Temporary Assistance for Needy Families:

USDA: U.S. Department of Agriculture:

WIC: Special Supplemental Nutrition Program for Women, Infants, and 
Children:

United States General Accounting Office:

Washington, DC 20548:

April 27, 2004:

The Honorable Thad Cochran: 
Chairman: 
The Honorable Tom Harkin: 
Ranking Democratic Member: 
Committee on Agriculture, Nutrition, and Forestry: 
United States Senate:

The Centers for Disease Control and Prevention (CDC) recently reported 
that poor nutrition and lack of physical activity are catching up to 
tobacco use as the leading cause of death in the United 
States.[Footnote 1] Poor nutrition has increased dramatically in recent 
decades and now accounts for about 300,000 preventable deaths each 
year. The proportion of the nation's children who are overweight nearly 
doubled over the last two decades, and the proportion of adolescents 
who are overweight almost tripled in the same period. Furthermore, 
between 1999 and 2000, two out of every three adults were obese or 
overweight. In addition to having negative health outcomes, children 
with poor nutrition may have a harder time concentrating and succeeding 
in school than other children.[Footnote 2] As a result, the nation is 
focusing more attention on the importance of good nutrition.

The U.S. Department of Agriculture (USDA), the lead agency for the 
nation's nutrition education efforts, funds and administers a variety 
of nutrition education efforts.[Footnote 3] One program, the Expanded 
Food and Nutrition Education Program (EFNEP), is designed specifically 
to provide nutrition education. In addition, four of USDA's largest 
nutrition assistance programs,[Footnote 4] while designed primarily to 
ensure that eligible individuals have access to low-cost or free food, 
also include nutrition education components. These programs are the 
Food Stamp Program (FSP); the Special Supplemental Nutrition Program 
for Women, Infants, and Children (WIC); the National School Lunch 
Program (NSLP); and the Child and Adult Care Food Program (CACFP). 
Together, they reached one in five Americans, from infants to the 
elderly, in 2002. Each of these programs has its own administrative 
structure, resources, and guidelines for providing nutrition 
education.[Footnote 5]In addition, two different USDA agencies oversee 
the programs; the Cooperative State Research, Education, and Extension 
Service (CSREES) oversees EFNEP,[Footnote 6] and the Food and Nutrition 
Service (FNS) oversees the four nutrition assistance programs. Only two 
of the programs have legislative requirements to provide nutrition 
education--EFNEP and WIC. Together, resources for nutrition education 
in these programs totaled about $472 million in fiscal year 2002. 
Depending on the program, nutrition education funds ranged from nearly 
$10 million to almost $250 million in fiscal year 2002, and programs 
spent between $0.20 and $103 per participant on nutrition education in 
that same year, according to USDA officials.

In view of the importance of good nutrition, you asked us to answer the 
following questions: (1) What key actions can officials take to 
increase the likelihood of success in nutrition education? (2) Do USDA, 
state, and local officials incorporate these actions into their 
nutrition education efforts during program design? (3) Do these 
officials incorporate these actions during service delivery? (4) Do 
these officials incorporate these actions during program evaluation?

To identify the key components believed to contribute to successful 
nutrition education, we conducted interviews with experts in the field 
of nutrition education research, reviewed key research on the topic, 
and reviewed GAO reports and other documents on performance-based 
management.[Footnote 7] To answer the questions related to USDA's 
nutrition education efforts, we conducted interviews with officials 
from each of the five USDA programs and reviewed program reports and 
studies. We also conducted interviews with cognizant state and local 
officials from each of the five programs in three states; we conducted 
site visits in Maryland and California and conducted telephone 
interviews with Michigan officials. We selected these states because 
they represented a range of geographic locations and received a range 
of funding levels for nutrition education. Our observations on the 
delivery of nutrition education are primarily based on our site visits 
and cannot be generalized to the programs nationwide. Finally, we 
identified and reviewed studies and evaluations of the programs' 
nutrition education efforts that were conducted over the last 10 years 
to determine whether these programs were meeting their nutrition 
education goals. (See app. I for more information on our scope and 
methodology.) We conducted our study from May 2003 to April 2004 in 
accordance with generally accepted auditing standards.[Footnote 8]

Results in Brief:

We identified several key actions that increase the likelihood that 
nutrition education will succeed in achieving its goals, based upon 
research on nutrition education, prior GAO reports, and other documents 
on performance-based management. The key actions occur in three phases 
of a nutrition education effort: program design, service delivery, and 
program monitoring and evaluation. First, during program design, 
responsible officials need to set clear program goals, identify 
specific target populations, and develop strategic plans that outline 
how the program will achieve its goals. Second, during the provision of 
nutrition education services, or service delivery, nutrition educators 
should assess the needs of the targeted populations, including 
nutritional and learning needs, and appropriately tailor services to 
meet those needs. For example, in providing services to non-English-
speaking pregnant women, nutrition educators would need to provide 
services that addressed the nutritional needs associated with pregnancy 
as well as provide those services in the participant's native language. 
Nutrition educators should also deliver services with an appropriate 
frequency and duration to ensure the content of the nutrition education 
services are sufficient to meet the program's goals. In addition, 
consistent nutrition messages should come through multiple channels of 
communication, which can reinforce positive nutritional behavior. 
Third, during program monitoring and evaluation, officials should 
monitor the services provided and who receives them, assess program 
outcomes, and evaluate whether the program has had the desired impact 
on participants. However, even when nutrition education efforts 
incorporate all of these actions, certain factors in the participant's 
environment, such as the availability of fresh fruits and vegetables or 
the prevalence of food advertising, can have a significant influence on 
a program's results. Accordingly, officials should be conscious of what 
environmental factors are affecting participants and work to address 
those factors.

In its nutrition education efforts, USDA generally incorporates the key 
program design actions that are likely to contribute to success, such 
as identifying target populations and setting nutrition education 
goals. However, USDA faces challenges coordinating and building 
linkages across the five different programs that provide nutrition 
education. The USDA programs share similar target populations and 
nutrition education goals. Specifically, the programs target some 
overlapping populations, such as low-income families, and each 
program's nutrition education goals focus on improving nutritional 
knowledge and changing dietary behavior. Given these overlaps, it is 
important that the programs build effective linkages and increase 
coordination efforts to make the most efficient and effective use of 
resources. At the federal level, USDA recognizes the value of 
coordination efforts among different programs that provide nutrition 
education. For example, USDA supports participation in nutrition-
related committees and the sharing of nutrition education materials on 
a department Web site. In addition, FNS and EFNEP have identified the 
need to take additional steps to increase coordination efforts among 
its programs in certain areas. However, there is limited evidence of a 
department-wide strategy to build effective linkages between EFNEP and 
the FNS programs. In the absence of an overall strategy to better link 
these programs, USDA missed opportunities to increase coordination 
efforts, such as more systematically planning services and developing 
programs, as well as sharing curricula, lessons learned, and data 
collection tools across the nutrition education efforts. At the state 
and local levels, linkages among programs are hindered by the different 
funding streams, personnel, and requirements for designing and 
delivering nutrition education for their target populations. For 
example, in one state we visited, USDA programs were administered by 
five different agencies, ranging from social service and health 
departments to a Cooperative Extension office.

We found that the USDA programs incorporated the service delivery 
actions likely to contribute to successful nutrition education in 
different ways and to varying extents, but they faced similar 
challenges that affected their ability to fully incorporate these 
actions. Service delivery approaches ranged from one-on-one counseling 
to broad media campaigns. The challenges included limited resources and 
systems for providing nutrition education and competing program 
requirements that took time or resources away from nutrition education. 
For example, the NSLP and CACFP programs lack a formal administrative 
structure to systematically deliver nutrition education and disseminate 
the nutrition education materials created by Team Nutrition. Similarly, 
although WIC staff members conducted preliminary needs assessments 
through basic intake questionnaires, they could not provide frequent 
and ongoing services because of limited resources and competing 
requirements. Specifically, WIC officials in the states we studied told 
us the time they could spend on nutrition education was limited to less 
than 20 minutes twice every 6 months per participant, in part because 
of requirements that they also provide information on drug and alcohol 
counseling, and other non-nutrition information and services.

The programs we reviewed did not fully incorporate the monitoring and 
evaluation actions that are key to performance-based management and 
likely to contribute to successful nutrition education. Most of the 
programs--with the exception of EFNEP--did not systematically monitor 
its nutrition education. Specifically, most of the programs did not 
collect data at the federal level on the types of nutrition education 
services provided and who received these services. For example, WIC 
does not systematically collect data at the federal level on the number 
and characteristics--such as age, gender, or income level--of 
participants receiving nutrition education. Nor does it collect data on 
the types of nutrition education provided or the length or frequency of 
nutrition education. In addition, most of the programs we reviewed did 
not collect data on potential outcomes of nutrition education. For 
example, only EFNEP collected data changes in the nutrition knowledge 
and dietary behavior of participants. Moreover, none of the programs 
conducted regular nationwide evaluations of its nutrition education 
efforts, largely because such research can be difficult and costly. 
Despite the absence of regular nationwide evaluations, USDA and others 
have conducted some limited or smaller-scale evaluations and studies of 
particular nutrition education efforts. However, the studies conducted 
over the last 10 years that we identified were not of sufficient scope 
or quality to allow us to determine whether the programs have met their 
nutrition education goals. For example, we identified a number of 
studies finding that EFNEP improved participants' nutrition knowledge 
or dietary behavior, but each of these was limited to one city or state 
and did not allow us to determine whether EFNEP as a whole was meeting 
its goals. In the absence of key monitoring and evaluating actions, 
federal and state officials had limited information about the nature of 
nutrition education, potential outcomes of those efforts, and the 
impact of their investments in nutrition education.

To help overcome the challenges associated with USDA's nutrition 
education efforts and to help programs incorporate the key actions 
related to successful nutrition education, we recommend that the 
Secretary of Agriculture ensure that the department develop a unifying 
strategy for its nutrition education efforts. The unifying strategy 
should, at a minimum, identify ways to increase coordination efforts 
and strengthen linkages among the nutrition education efforts. It 
should also explore options to collect reliable data on services and 
recipients, identify and disseminate lessons learned, and consider a 
longer-term evaluation strategy. USDA generally agreed with our 
recommendations and suggested a number of technical corrections to the 
report, which we incorporated.

Background:

Efforts to educate individuals about the benefits of healthy eating and 
nutrition occur at the federal, state, and local levels through a 
variety of different agencies and programs. However, the USDA leads the 
nation's nutrition education efforts, providing nutrition education 
through the EFNEP program and through four of its major nutrition 
assistance programs. The extent to which nutrition education is 
integrated into nutrition assistance programs varies. In some programs, 
such as WIC, it is a mandatory component of the program. In others, it 
plays a lesser role. Each program has different legislative 
requirements and administrative structures for its nutrition education 
efforts. In addition, each program has a particular funding level to 
support its nutrition education efforts.

USDA Is the Lead Federal Agency Responsible for Nutrition Education:

Several federal agencies support nutrition education.[Footnote 9] 
However, in 1977, USDA was named the lead agency for nutrition 
research, extension, and teaching.[Footnote 10]Among USDA's wide array 
of responsibilities--including overseeing the nation's forests, 
conserving the nation's resources, and leading the nation's anti-hunger 
efforts--it provides nutrition education through the EFNEP program and 
four of its nutrition assistance programs.

In recent years, USDA has shifted its nutrition education focus from 
providing and disseminating nutrition information to more directly 
fostering changes in dietary behavior. USDA sets program regulations 
and guidelines that support its broad nutrition education goal, which 
is to provide an integrated nutrition education program that 
contributes to a nutritionally knowledgeable public, motivated to make 
behavioral change to promote optimal health and nutritional status. 
Within USDA, the Center for Nutrition Policy and Promotion oversees 
nutrition education policy and develops and maintains the Dietary 
Guidelines for Americans and the Food Guide Pyramid. USDA tries to 
ensure that its nutrition education integrates the messages established 
in USDA's Dietary Guidelines for Americans and the Food Guide 
Pyramid;[Footnote 11] these efforts help USDA officials ensure some 
consistency across their nutrition education efforts.

Each of USDA's Programs That Provide Nutrition Education Has a 
Different Overall Mission, Legislative Requirement, Administering 
Entity, and Nutrition Education Funding Level:

The five USDA programs that provide nutrition education differ in their 
overall mission and their legislative requirements, administering 
entities, and funding levels for nutrition education. First, only one 
of the five programs--EFNEP--is uniquely a nutrition education program; 
the four other programs are primarily nutrition assistance programs. 
These programs provide nutrition education through an array of state 
and local administering entities, from health and education departments 
to Cooperative Extension offices, a network of educators in 
universities and county offices. While these programs may differ 
operationally, they have the potential to reach a broad population with 
their nutrition education efforts.

EFNEP:

EFNEP is a federally funded program specifically designed to educate 
low-income families and youth about nutrition and nutrition-related 
subjects, such as food safety and food budgeting. (See table 1.) USDA 
initiated the program in fiscal year 1969 to help low-income families 
better understand nutrition and manage their food resources. EFNEP is 
administered at the state level by Cooperative Extension offices, which 
oversee the allocation of federal EFNEP funds. Federal EFNEP funds are 
allocated to states based on population data from the decennial census. 
Cooperative Extension offices then allocate EFNEP funds to county 
extension offices by targeting first those counties with the highest 
levels of poverty.

Table 1: Characteristics of EFNEP:

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

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

Legislative requirement to provide nutrition education (Yes or No): 
Yes.

State administering entity: Cooperative Extension Service.

Local administering entity: County Extension offices.

Description of nutrition educator: Paraprofessionals and volunteers.

Source: USDA and 7 U.S.C. § 3175-3175e.

[End of table]

WIC:

First authorized in 1974, WIC provides supplemental food and nutrition 
education to low-income pregnant, breast-feeding, and postpartum women 
and to infants and children under age 5. (See table 2.) In fiscal year 
2000, the WIC program served almost half of all infants and about one-
quarter of all children ages 1 through 4 in the United States. WIC is 
federally funded, and most of the program's resources are allocated for 
providing participants with paper vouchers in exchange for approved 
foods at grocery stores, including milk, juice, and cereal. However, 
federal program regulations require that each state expend at least 
one-sixth of its nutrition services and administration grants on 
nutrition education. This education must be offered to all WIC 
caregivers. However, WIC participants cannot be denied the other WIC 
benefits because they do not attend nutrition education activities.

Table 2: Characteristics of WIC:

Program participation in FY2002: $7.5 million[A]. 

Federal program costs for FY2002: Over $4.3 billion.

Federal expenditures for nutrition education for FY2002: $247 million.

Legislative requirement to provide nutrition education (Yes or No): Yes.

State administering entity: 88 state agencies, consisting of state 
health departments, Indian tribes, or intertribal councils.

Local administering entity: Over 10,000 local service sites or clinics, 
including health departments, community centers, and schools, for 
example[B].

Description of nutrition educator: Dieticians, nurses, or other health 
professionals or paraprofessionals. 

Source: USDA and 42 U.S.C. § 1786.

[A] WIC participation data are based on annual averages.

[B] Some state-level agencies operate the program at both the state and 
local levels rather than distributing WIC funds to local agencies.

[End of table]

Food Stamp Program:

The Food Stamp Program enables low-income families to purchase 
nutritious foods at retail stores with electronic-based benefits. (See 
table 3.) While there is no legislative mandate for nutrition 
education, states have the option to use administrative funds to 
provide nutrition education as a component of the FSP known as Food 
Stamp Nutrition Education (FSNE).[Footnote 12] In order to provide 
nutrition education, the state agency administering FSP is responsible 
for submitting a state nutrition education plan for FSNE. However, 
state agencies that determine food stamp eligibility generally do not 
have the professional staff and experience to provide nutrition 
education. Therefore, the traditional providers of nutrition education 
under FSNE have mostly been affiliated with the Cooperative Extension 
Service, the same entity that administers EFNEP. In addition, state 
Nutrition Networks, which include government, nonprofit and business 
organizations, have cooperative agreements with FNS to identify and 
respond to nutrition problems at the state level.

Table 3: Characteristics of FSP:

Program participation in FY2002: 19.1 million[A]. 

Federal program costs for FY2002: $20.7 billion (food stamp benefits 
and administration).

Federal expenditures for nutrition education for FY2002: $156.1 
million.

Legislative requirement to provide nutrition education (Yes or No): No.

State administering entity: State social service agencies administer 
the Food Stamps Program. However, most states contract with USDA's 
Cooperative Extension for delivery of nutrition education through FSNE. 
In some cases, state nutrition networks, public health departments, 
welfare agencies, and university academic centers administer FSNE.

Local administering entity: Social service offices determine 
eligibility for food stamp benefits. However, FSNE is usually provided 
in county extension offices, community-based centers, schools, day care 
and Head Start centers, WIC clinics, etc.

Description of nutrition educator: Professionals or paraprofessionals. 

Source: USDA and 7 U.S.C § 2011-2036.

[A] FSP participation data is based on average monthly participation.

[End of table]

NSLP and CACFP:

The NSLP and CACFP programs provide nutritionally balanced meals at low 
or no cost. (See table 4.) NSLP provides nutritionally balanced, 
federally subsidized meals for all children in public and nonprofit 
schools and residential child care institutions, with the size of the 
subsidy dependent on the income level of participating 
households.[Footnote 13] Similarly, CACFP provides nutritious meals and 
snacks to children in nonresidential child care and chronically 
impaired adults or adults age 60 or older in nonresidential day care 
facilities. FNS administers both programs at the federal level. At the 
state level, state education agencies typically administer and monitor 
the program. For NSLP, funding flows to the local school food 
authorities--offices responsible for managing the meals program. For 
CACFP, funding flows to sponsoring agencies, generally nonprofit 
agencies. Neither program has a legislative requirement to provide 
nutrition education, and unlike EFNEP and the other FNS programs, 
neither NSLP nor CACFP has funding specifically to support nutrition 
education. However, USDA established the Team Nutrition initiative in 
1995 to promote nutrition education activities through these child 
nutrition programs.[Footnote 14] Specifically, Team Nutrition provides 
grants to states and develops and disseminates technical assistance 
materials on how to build school and community support for healthy 
eating, physical activity, and a healthy nutrition environment. 
However, while Team Nutrition, which was funded at $10 million in 
fiscal year 2002, funds the development of nutrition education messages 
and materials, it does not fund the staff and other resources needed to 
deliver nutrition education.

Table 4: Characteristics of NSLP and CACFP:

Program participation in FY2002: 
NSLP: 28 million children[A]; 
CACFP: 2.9 million[B].

Federal program costs for FY2002: 
NSLP: $6.1 billion; 
CACFP: $1.9 billion.

Federal expenditures for nutrition education for FY2002: 
NSLP: $10 million through Team Nutrition; 
CACFP: [Empty].

Legislative requirement to provide nutrition education (Yes or No): 
NSLP: No; 
CACFP: [Empty].

State administering entity: 
NSLP: Department of education; 
CACFP: Department of education, health, or social services.

Local administering entity: 
NSLP: Public and private nonprofit schools and residential child care 
institutions; 
CACFP: Child care centers, after-school and Head Start centers, and day 
care homes.

Description of nutrition educator: 
NSLP: School food service personnel and teachers; 
CACFP: Day care providers. 

Source: USDA and 42 U.S.C. § 1751-1770.

[A] NSLP participation data are based on 9-month averages.

[B] Participation data represent average daily attendance with no 
adjustment for absenteeism. Data were collected monthly through fiscal 
year 1982, and quarterly in subsequent years.

[End of table]

Overall Funding for Nutrition Education Has Grown over the Last Decade:

As shown in figure 1, funding for nutrition education has grown over 
the last decade, primarily driven by increases in WIC and FSNE; funding 
for Team Nutrition and EFNEP has remained relatively stable or grown 
only slightly.

Figure 1: USDA Nutrition Education Expenditures Have Increased Overall 
between Fiscal Years 1992 and 2002:

[See PDF for image]

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

[End of figure]

Several Actions Are Key to Performance-Based Management and Successful 
Nutrition Education:

Several actions are key to performance-based management and likely to 
contribute to successful nutrition education, based upon nutrition 
education research, prior GAO reports, and other documents on 
performance-based management. On the basis of this work, program 
officials should take these actions during program design, service 
delivery, and program monitoring and evaluation. During service 
delivery, nutrition educators need to assess participants' needs and 
tailor services to meet those needs. Providing consistent messages 
through multiple delivery channels is also beneficial to encouraging a 
positive change in a participant's nutritional behavior. Last, during 
program monitoring and evaluation, officials need to collect and 
monitor program service and participant data, assess outcomes, and 
evaluate whether the nutrition education has had the desired impact. 
Research indicates that, along with these key actions, environmental 
factors can have a significant positive or negative influence on the 
results of nutrition education and should be considered when designing, 
delivering, and monitoring and evaluating nutrition education efforts.

Key Actions in Nutrition Education Can Increase the Likelihood of 
Success:

We identified several key actions presented in general nutrition 
education research, prior GAO reports, and other documents on 
performance-based management that program officials should take during 
any nutrition education program. These actions reflect an ideal. 
However, if seriously addressed, these actions will increase the 
likelihood that the nutrition education will achieve its goals. These 
actions occur at three separate stages in a nutrition education 
program: program design, service delivery, and program monitoring and 
evaluation. However, the framework does not prescribe a single method 
of program design, service delivery, or program monitoring and 
evaluation; broad principles underpin these actions, which allows for 
flexibility, multiple approaches to nutrition education delivery, and 
various contexts in which nutrition education can take place. Figure 2 
depicts these actions and the three stages in which they occur.

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

[See PDF for image]

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

[End of figure]

According to this framework, during program design officials need to 
identify their specific targeted population, set clear program goals, 
and conduct strategic planning, which together provide the necessary 
foundation to help guide the rest of the actions. Identifying the 
target population can help program officials focus their goals and 
planning efforts appropriately. Program goals should be clear and 
measurable, so officials can determine whether the program is 
succeeding. Next, program officials need to conduct strategic and other 
planning efforts that detail how they intend to meet their nutrition 
education goals. For example, strategic plans should include the 
program goals, plus objectives, performance measures, and strategies 
that they will use to achieve the goals and objectives. In addition, 
plans should also include information on how program officials will 
coordinate and plan crosscutting efforts with other related federal 
programs.

During service delivery, nutrition educators need to assess the needs 
of participants, tailor services to meet those needs, and deliver 
services of appropriate frequency and duration to meet program goals. 
In assessing participant needs, nutrition educators need to identify 
the nutritional, health, and learning needs of the participants and 
tailor the nutrition education activities to address those needs. For 
example, in providing services to non-English-speaking pregnant women, 
nutrition educators would need to provide services that addressed the 
nutritional and health needs associated with pregnancy as well as 
provide those services in the participant's native language. Programs 
should support needs assessments of the targeted population receiving 
nutrition education services. Research indicates that individual 
participant assessments can be a powerful tool in providing services 
and are particularly important when the participant has a high level of 
nutritional risk, such as in cases of low hemoglobin levels.[Footnote 
15] However, programs may also assess the needs of a selected group of 
participants, such as low-income women living in a given community, and 
tailor services to meet the group's needs. These broader assessments 
can also increase the likelihood of a program's success, and are often 
present in efforts that employ social marketing, an audience-centered 
approach that features multiple and reinforced channels of 
communication along with public policy and environmental changes to 
influence behavior.[Footnote 16] In addition, educators who live in the 
community in which they teach, referred to as paraprofessionals in the 
EFNEP program, may have an enhanced understanding of participant 
needs.[Footnote 17]

Finally, nutrition educators also need to deliver services with an 
appropriate frequency and duration to ensure the content of the 
nutrition education services is sufficient to meet the program's goals. 
Experts agree that positive nutritional behavior change requires active 
and sustained participation for a duration that is significantly longer 
than what is needed for a gain in nutritional knowledge. Nutrition 
educators can help ensure that participants receive a sustained and 
consistent message by delivering services through multiple channels. By 
doing so, nutrition education messages are supported and emphasized, 
and also can increase the likelihood of services reaching participants 
who may not be able to come into a traditional classroom to receive the 
nutrition education.

During program monitoring and evaluation, program officials need to 
collect data and evaluate program impact to monitor their nutrition 
education efforts and evaluate the program's influence on participant 
behavior. Output data, such as how many participants received services 
and what services the program provided, enable officials to monitor 
general program operations. Outcome data, such as pre-and postprogram 
dietary behavior, provide valuable information on whether a 
participant's knowledge or behavior has changed following the nutrition 
education. Finally, program evaluations with an experimental or quasi-
experimental design help determine whether it is the nutrition 
education that caused the knowledge or behavior changes, rather than 
other factors. Officials can use all this information to review their 
successes and failures, diagnose problems, and explain results. 
Officials can then use this information to retool the program design or 
service delivery to further increase the chances of success.[Footnote 
18]

Environmental Factors Can Challenge or Support Nutrition Education 
Efforts:

A complex set of factors, including circumstances in the participant's 
environment outside the classroom, contributes to an individual's 
decisions about dietary behavior. Research indicates that these factors 
can influence the results of education efforts. For example, food 
advertising, lack of support from family members, and easy access to 
unhealthful foods can make it more difficult for participants to make 
the healthy choices presented in their nutrition education classes. For 
example, some, but not all, foods sold in schools separate from the 
regulated school meals program are high in fat, sodium, or added 
sugars. These foods are available in many schools and can compete with 
the more healthful foods available in schools.[Footnote 19] Outside of 
the school environment, participants face additional challenges if 
healthy foods, such as fruits and vegetables, are not readily available 
in local stores. Poverty and unstable monthly incomes can also affect a 
family's ability to routinely eat nutritious foods.

Program officials also described situations when environmental factors 
may support nutrition education efforts. For example, one official said 
the increasing health concern regarding obesity has generated more 
community support for healthy eating choices. In addition, nutrition 
education participants in rural communities with an abundance of 
locally grown produce and vegetables may find it easier to incorporate 
some of the lessons from their programs into their daily diets.

When nutrition education activities address environmental factors that 
can work against healthy eating choices or leverage environmental 
factors that support healthy choices, they may be more likely to 
improve participants' dietary behavior. Social marketing often 
addresses environmental factors. For example, through a social 
marketing approach, local public agencies could work in partnership 
with private business to establish produce sections in convenience 
stores located in low-income neighborhoods that do not have grocery 
stores. By then providing nutrition messages about fresh fruits and 
vegetables through multiple channels--such as local media and other 
community outlets--the effort may be able to increase local supply and 
demand for healthful foods.

Although USDA Generally Incorporates the Key Program Design Actions 
Likely to Contribute to Success, Establishing Linkages among Programs 
Is Difficult:

In its nutrition education efforts, USDA generally incorporates the key 
program design actions that are likely to contribute to success, such 
as identifying target populations and setting nutrition education 
goals. The programs share similar target populations and nutrition 
education goals, increasing the need for program officials to work 
together to make the most efficient and effective use of resources. 
However, USDA faces challenges increasing coordinating efforts and 
building and strengthening linkages across the five different programs 
that provide nutrition education. At the federal level, USDA recognizes 
the value of coordination among different nutrition education efforts. 
However, there is limited evidence of a department-wide strategy to 
build effective linkages among programs, particularly between EFNEP and 
the FNS programs.

USDA's Nutrition Education Programs Identified Target Populations and 
Goals:

USDA's nutrition education efforts incorporate the key actions of 
defining their target populations and goals. While the programs' target 
populations for nutrition education are not identical, there is 
considerable overlap among them. (See table 5.) Most of USDA's 
nutrition education efforts target primarily low-income individuals and 
families, although nutrition education through NSLP or CACFP can target 
any person in a participating school or child care or adult day care 
center.

Almost all of USDA's programs use the same eligibility requirements for 
nutrition education that they use for their other services associated 
with the program, such as the receipt of WIC vouchers. One program, 
FSP, grants waivers to state agencies allowing FSNE to target a broader 
population than that of people receiving food stamps. However, states 
are required to demonstrate that these nutrition education efforts are 
generally targeted to program recipients and that the majority of FSNE 
participants are low-income.[Footnote 20]

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

Program: EFNEP; 
Target population for nutrition education: Low-income youth and low-
income families with children; 
Eligibility for program services: There are no specific eligibility 
requirements, but EFNEP providers are encouraged to target EFNEP to 
families on other types of low-income assistance, such as food stamps, 
or to neighborhoods or schools with high rates of poverty.

Program: WIC; 
Target population for nutrition education: Low-income pregnant, 
postpartum, and breast-feeding women; infants; and young children 
receiving WIC; 
Eligibility for program services: 185% of poverty or less, and assessed 
as having "nutritional risk"[A].

Program: Food Stamp Program; 
Target population for nutrition education: Low-income children and 
families receiving food stamps[B]; 
Eligibility for program services: 130% of poverty or less[B].

Program: NSLP; 
Target population for nutrition education: School children; 
Eligibility for program services: At or below 130% of poverty for free 
meals, between 130% and 185% for reduced price; no restrictions for 
full-priced meals[C].

Program: CACFP; 
Target population for nutrition education: Children in nonresidential 
day care and adults in day care facilities that participate in CACFP 
and adults over 60 in adult day care centers or chronically disabled 
persons in adult day care centers; 
Eligibility for program services: Children 12 and under, migrant 
workers' children 15 and under, children 18 and under residing in 
residential child care facilities, and functionally impaired adults or 
adults over age 60 in care centers[D]. 

Source: USDA.

[A] In 2003, the poverty level for a family of three was $15,260 for 
the 48 contiguous states. EFNEP does not require participants to 
provide eligibility documentation. However, the program specifically 
targets audiences located in low-income neighborhoods, schools, 
community center, etc.

[B] In 2002, all 50 states had approved waivers allowing them to 
provide nutrition education funded by the Food Stamp Program to non-
food stamp participants.

[C] In school year 2002-2003, USDA reimbursed participating schools 
$2.14 for every free lunch meal provided, $1.74 for every reduced price 
lunch meal sold, and $0.20 for every other lunch meal served.

[D] For more information about the definition of a functionally 
impaired adult, see USDA's CACFP regulations under 7 C.F.R. § 226.2.

[End of table]

All five of the USDA programs that provide nutrition education also 
share the overall nutrition education goal to improve nutritional 
knowledge and dietary behavior, as shown in appendix II. Officials from 
each of these programs told us that state officials have flexibility to 
set more specific nutrition education goals. For example, in addition 
to setting the federal FSP goal, state FSNE officials in a number of 
states set the specific goal of increasing the consumption of fresh 
fruits and vegetables.

While USDA sets goals for its nutrition education efforts, the 
department does not include measures that specifically assess its 
nutrition education efforts. For example, both USDA and FNS have 
strategic plans that include the goal of improving the nation's 
nutrition and health. However, neither strategic plan includes measures 
for assessing the effects of the nutrition education efforts. To assess 
progress toward its goals, USDA uses a broad national index--the 
Healthy Eating Index--a measure of diet quality among Americans with 
incomes under 130 percent of poverty and children in households under 
185 percent of poverty. Although this measure is helpful in tracking 
changes in the diet quality of the target population, it is not tied to 
participation in nutrition education efforts. Therefore, it is 
difficult to determine whether changes in participant behavior are 
influenced by program nutrition education efforts or other factors. In 
addition, neither USDA's strategic nor its performance plans include 
other interim measures that can be more closely linked to program 
success or outcomes.

Some Coordinating Efforts Exist across Programs Providing Nutrition 
Education, but Strong Linkages Are Absent:

When programs have similar goals and serve similar and potentially 
overlapping target populations, it is important that some mechanisms 
exist that support an array of coordinated activities in order to make 
the most efficient and effective use of resources. On one hand, overlap 
creates the potential for unnecessary duplication of, or gaps in, 
service delivery as well as administrative inefficiencies. On the other 
hand, overlap between agencies or programs that administer similar 
functions is sometimes necessary to meet federal priorities, and in the 
case of nutrition education, participants can benefit from hearing the 
message from several sources. To be effective, the messages across 
programs must be consistent with one another, which requires 
established linkages across programs.

USDA recognizes the value of coordinating efforts among these programs; 
in practice, the programs coordinate in various ways. FNS and EFNEP 
staff participate in multiple committees and initiatives within USDA 
and with other federal and nongovernmental organizations to work 
together on specific nutritional issues. For example, officials from 
USDA and the Department of Health and Human Services participate in a 
working group to ensure that dietary guidance from both departments 
accurately reflects the Dietary Guidelines for Americans and the Food 
Guide Pyramid.[Footnote 21]

In addition, the programs work with the Food and Nutrition Information 
Center (FNIC) at the National Agricultural Library to provide a forum 
for the exchange of nutrition education information among programs and 
with state and local officials and nutrition educators. However, FNS 
materials are separate from EFNEP's. FNIC has a memorandum of 
understanding with FSNE, WIC, and Team Nutrition to support their 
nutrition education materials through FNIC's Web site.[Footnote 22] The 
Web site houses a wide array of nutrition education materials, 
including multiple databases containing nutrition education curricula. 
For example, the Web site supports the Food Stamp Nutrition Connection 
database, which provides a forum for nutrition educators to share 
curricula, participant materials, and other resources with personnel 
providing nutrition education activities to food stamp participants, 
applicants, and other low-income individuals likely to be eligible for 
FSP. Similarly, the Healthy School Meals Resource System provides 
information to persons working in USDA's child nutrition programs. In 
addition, FNIC also supports links to discussion groups that allow 
providers of nutrition education to communicate and exchange ideas. 
While there is useful information available through FNIC, we do not 
know the extent to which nutrition educators use these resources. 
Furthermore, FNIC's Web site does not include either the database of 
nutrition education materials created primarily by EFNEP or a link to 
this database. Instead, CSREES supports the Nutrition Education for 
Diverse Audiences database, which contains nutrition education 
curricula and other related material on its Web site.[Footnote 23] 
These materials can be a valuable resource for those individuals who 
take advantage of them; however, USDA does not systematically ensure 
coordination or the sharing of materials among the programs, 
particularly between FNS and EFNEP.

FNS has identified the need to take additional steps to strengthen the 
overall linkages among its programs. For example, as part of the 
department's strategic goal to promote healthier eating habits and 
lifestyles, it has listed a strategy to support an integrated, cross-
program nutrition education effort to address health-related problems, 
such as obesity. However, the plan does not describe the specific 
means, mechanism, or responsible authority to implement this strategy. 
In addition, FNS has recognized the need for a more integrated, cross-
program approach in its 1999 report to Congress, the President's fiscal 
year 2005 budget request, and other documents. For example, in its 
report to Congress,[Footnote 24] FNS states that its goal is to ensure 
that nutrition education is fully integrated into all FNS programs; 
specifically, FNS says the changes needed to enhance nutrition 
behaviors can only be achieved through a nutrition education effort 
that allows flexibility for integrated, cross-program interventions. In 
the report, FNS suggests that funding be authorized for such cross-
program coordination. In the budget request, FNS is requesting a total 
appropriation of $2.5 million for cross-program nutrition education 
efforts, including establishing a cross-program nutrition framework 
with the goal of ensuring a comprehensive, integrated, and family-
oriented approach in all FNS nutrition assistance programs.[Footnote 
25] The funds would support increased coordinating efforts, such as the 
formulation of curricula, the sharing of best practices across FNS 
program participants, and the fostering of collaboration among state 
agencies.

Despite these initiatives and proposals, overall, we found limited 
evidence of a department-wide unifying strategy to build and support 
effective linkages among the FNS programs and EFNEP that would ensure 
consistency of message, efficient use of resources, and planning for 
service delivery and program development at the federal level. 
Increasing coordination efforts and building strong linkages between 
EFNEP and FNS may be challenging because they are administered by two 
different USDA agencies. For example, we identified missed 
opportunities to share data collection tools and software that could 
have helped with both program efficiency and effectiveness. However, 
some federal officials we spoke with have recognized the need to 
improve linkages between the two USDA agencies. An FNS official said 
that FNS has begun to focus efforts on ways to ensure that nutrition 
messages are coordinated across its programs. However, it has not yet 
worked with EFNEP on this issue. An EFNEP official said that FNS and 
CSREES are beginning to see the need for enhanced coordination and have 
begun to discuss activities that could go in a memorandum of 
understanding.

Distinct administrative structures can also create coordination 
challenges and fragmented service delivery at the state level and local 
level. Specifically, state and local officials are hindered by the 
different administrative structures of each of the programs, including 
the funding streams, personnel, and requirements for designing and 
delivering nutrition education for their target populations. For 
example, in one state we visited, USDA programs were administered by 
five different agencies, ranging from social service and health 
departments to a Cooperative Extension office. Moreover, states often 
lack a process or a central focal point to help coordinate planning 
efforts among the programs. In our report on NSLP, we noted that not 
all states had established a state focal point for leadership or had 
begun collaboration among state agencies to provide nutrition education 
in schools.[Footnote 26] In the past, the Nutrition Education and 
Training Program helped to fund this central focal point by providing 
the manpower and resources needed for state and local officials to 
coordinate child nutrition programs with nutrition education activities 
in schools and child care centers. Despite the lack of a central focal 
point, we did find instances of local coordination across some 
programs, but this coordination was sporadic and generally involved two 
programs rather than all of them.

USDA has taken some steps to encourage and facilitate linkages between 
some of its programs that provide nutrition education. At the state 
level, FNS established cooperative agreements with 22 states to 
establish Nutrition Networks, which can act as the collaborative agent 
at the state level to help identify and highlight nutrition problems, 
such as obesity.[Footnote 27] Nutrition Networks are state-level 
organizations that can expand, coordinate, and integrate innovative 
nutrition education messages across programs.[Footnote 28] 
California's Nutrition Network, for example, includes over 300 
government, nonprofit, and business organizations, including the state 
Departments of Health Services, Social Services, Education, and Food 
and Agriculture, and the state's Cooperative Extension system. State 
officials said that one of the many goals of its network is to identify 
service gaps across nutrition education efforts. USDA also recently 
began an initiative to promote collaboration, known as the State 
Nutrition Action Plans initiative. This initiative encourages state 
agencies to work together toward a more integrated approach to planning 
and delivering nutrition education. When the initiative was launched at 
its national conference, FNS asked state officials to work together to 
identify goals for collaboration and specific objectives and steps to 
achieve the goals. However, the Nutrition Networks are not nationwide, 
and the State Nutrition Actions Plans initiative is still in the early 
stages of development.

Programs Incorporated the Service Delivery Actions in Different Ways 
and to Varying Extents but Faced Similar Challenges to Incorporating 
Them:

We found that the USDA programs incorporated the service delivery 
actions likely to contribute to successful nutrition education in 
different ways and to varying extents, but they faced similar 
challenges that affected their ability to fully incorporate these 
actions. Service delivery ranged from one-on-one counseling to broader 
media campaigns. However, challenges such as competing requirements and 
resource constraints limited each program's ability to fully 
incorporate all of the service delivery actions.

EFNEP Incorporated Key Service Delivery Actions, but Services May Not 
Have Reached Many Eligible Participants because of Resource 
Constraints:

As the only USDA program we reviewed whose primary mission is to 
deliver nutrition education, EFNEP was able to consistently assess 
participant needs, tailor services to meet those needs, and provide 
frequent nutrition education. However, officials at state Cooperative 
Extension offices, EFNEP's administering entity, expressed concern over 
their ability to provide equitable services to those in need because of 
existing funding formulas and resource constraints.

A federal EFNEP official told us the program assessed participant needs 
for nutrition education by routinely having participants fill out 
either a food behavior checklist or other questionnaires, which asked 
about what the participant had eaten the previous day. These 
assessments provided instructors with important indicators of nutrition 
and dietary behavior. States had the option of gathering additional 
information from participants. For example, California added two more 
questions to the assessment form that determined participants' fruit 
and vegetable intake. In addition, EFNEP uses paraprofessionals to 
deliver nutrition education, and their presence in these communities 
may augment their ability to assess local needs. An EFNEP official in 
Michigan, for example, stated that having EFNEP paraprofessionals who 
lived in a Native American community enhanced their ability to 
determine the needs of that community.

The EFNEP program has a core curriculum that includes classes on 
dietary practice, nutrition quality, food safety, food security, and 
resource management. However, EFNEP officials we spoke with stated that 
the program allows educators to tailor parts of the curriculum to 
address participants' needs. For example, Michigan EFNEP officials told 
us their paraprofessionals developed an individual plan for 
participants tailored to each participant's responses to questions from 
the formal needs assessment.[Footnote 29] The individual plans included 
the core curriculum of the particular program but also included areas 
for emphasis or supplementation within the curriculum. Similarly, 
California EFNEP introduced a nutrition program into public schools 
called EatFit. With the goal of increasing nutrition and health among 
school children, the program included participant self-assessments, 
which drove the specific curriculum and messages provided through the 
program's series of classes. The children received tailored 
interventions, based on the assessments, with goals such as increasing 
fruit intake at lunch and increasing physical activity throughout the 
school day.

EFNEP officials told us they delivered frequent and ongoing nutrition 
education. Specifically, EFNEP educators provided a series of 
interventions, which varied in number from 6 to 16, generally in the 
form of small group classes over the course of approximately several 
months to a year, depending on the number of interventions.[Footnote 
30] EFNEP educators provided nutrition education through various sites, 
such as WIC clinics, 4-H clubs, community centers, and other key sites 
in the community. Research indicates that providing nutrition education 
through various sites is beneficial to participants. However, officials 
noted that while the delivery of classes over the course of several 
months helped ensure participants benefited from the services, this 
benefit could diminish after the nutrition education ended.

A federal program official told us that resource constraints and 
funding formulas presented challenges for equitable service delivery. 
Given its current resources, the program is currently able to fund 
services in approximately 700 to 800 of the nation's 3,150 counties. 
This is, in part, because EFNEP funding has declined in constant 
dollars over several decades despite a general increase in the number 
of people eligible for EFNEP services. Furthermore, an EFNEP official 
said the funding formula for allocating program resources among states 
is outdated. It is based on census data from the 1960s. As a result, 
states such as California, where the low-income population has 
increased over the last two decades, had less to spend per eligible 
participant than states with more stable low-income populations. For 
example, while California spent roughly 65 cents per eligible 
participant in 2003, South Dakota spent over $5.00 per eligible 
participant.

Some state and local EFNEP providers delivered nutrition education in 
collaboration with other USDA nutrition education programs to broaden 
their reach, according to officials with whom we spoke. For example, in 
Michigan, EFNEP officials told us they leveraged program resources by 
working with the local FSNE initiative to ensure that the geographic 
areas where they provided services did not overlap.

WIC's Ability to Incorporate the Key Service Delivery Actions May Have 
Been Limited by Competing Program Requirements and Resource 
Constraints:

WIC provides nutrition education services as a part of the program's 
overall nutrition assistance mission, but officials we spoke with told 
us several competing program requirements and resource constraints 
limited the program's ability to fully incorporate all of the service 
delivery actions. WIC staff we met with told us their educators, 
usually nutritionists or dieticians, routinely assessed participant 
needs and usually tailored the services to the needs of the WIC 
population in general.[Footnote 31] However, WIC had a limited ability 
to deliver frequent and ongoing nutrition education. In addition, other 
program requirements restricted the time and resources available for 
nutrition education.

WIC officials told us that by requiring participants to complete an 
intake form that helped providers identify their nutritional intake and 
dietary behaviors, WIC routinely assessed participants' needs. WIC 
providers, which included local public and private nonprofit health 
clinics and nonprofit agencies, used these forms to identify high-
nutritional-risk participants, who, according to federal officials, 
were slated for more intensive, one-on-one nutritional 
counseling.[Footnote 32] Some WIC providers we spoke with also used the 
intake forms to collect data on the characteristics and dietary needs 
of the program participants overall. Michigan has developed a computer 
system for collecting and tracking participant needs that, according to 
state officials, assisted the state's local providers in knowing what 
nutrition education services were most needed, the number of nutrition 
education interventions, the number of participants who refused WIC 
nutrition education, and the number of participants enrolled in other 
programs such as Temporary Assistance for Needy Families (TANF) and 
Medicaid.

Federal WIC officials told us that WIC providers try to tailor 
nutrition education to participant needs when possible, although in 
most cases, participants received nutrition education tailored to the 
needs of the overall WIC population. For example, a Michigan official 
stated that her staff designed nutrition education classes that were 
appropriate for the general WIC community, and participants generally 
received whatever pre-designed class happened to be offered on the day 
they were in the clinic. WIC officials told us that local WIC providers 
use participant data to help tailor services. For example, a Maryland 
WIC official said the state database included several data elements 
that are helpful in tracking local participant health trends, which 
allowed local clinics to adjust and develop their overall curriculum to 
address the needs of the local participants. Several officials stated 
that given the limited resources and time for WIC nutrition education, 
it was impossible to ensure participants received nutrition education 
that addressed their particular needs except for participants at the 
greatest nutrition risk.

Federal, state, and local WIC officials we interviewed said the WIC 
program had a limited ability to provide frequent and ongoing nutrition 
education because of competing program requirements. According to 
program rules, WIC providers are required to offer nutrition education 
to participants. However, those who do not attend nutrition education 
activities cannot be denied the other WIC benefits for their lack of 
participation. Moreover, the cost of nutrition education in WIC is a 
part of each local agency's administrative expenses, which, according 
to FNS officials, forces nutrition education activities to be in 
competition for resources with other administrative requirements and 
duties.[Footnote 33] For example, WIC providers were required by law to 
provide services unrelated to nutrition education, such as voter 
registration and drug and alcohol counseling. Because of these 
competing demands on time and resources, the average WIC participant 
received approximately less than 20 minutes of nutrition education 
twice every 6 months.[Footnote 34] WIC participants usually receive WIC 
services over the course of several years, which allows a more 
sustained participation in nutrition education services, according to 
FNS officials. However, WIC officials in both California and Michigan 
stated that there was little reason to believe such a limited exposure 
to nutrition education would produce meaningful changes in a 
participant's nutritional knowledge and dietary behavior.

In response to these challenges, FNS and the states we studied were 
developing technology-driven approaches to nutrition education. FNS, in 
partnership with other organizations, established the WIC Works 
Resource System in January 2000. This Web-based system includes an on-
line searchable database of materials developed for WIC audiences and 
downloadable materials from the childhood obesity prevention 
initiative, Fit WIC. At the state level, Michigan officials told us 
they were trying to improve access to services by providing some 
participants with the option of receiving services through self-paced 
Internet classes. In addition, state WIC officials have collaborated 
with other USDA efforts to deliver nutrition education. State officials 
we interviewed cited examples of WIC officials working with other 
programs, such as EFNEP, to develop nutrition education curricula, but 
again time, resources, and other program priorities limited their 
efforts.

FSNE's Incorporation of the Service Delivery Actions Varies Widely, and 
Food Stamp Recipients May Not Be Receiving FSNE Services:

Designed as an optional service for states to provide in conjunction 
with other food stamp services, FSNE service delivery varies widely 
from state to state. Services in FSNE can range from one-on-one 
counseling to small group classes, to broad social marketing campaigns 
that reach large numbers of people at a low cost per participant. All 
of these delivery methods could incorporate the key delivery actions if 
implemented properly. However, not enough is known about the services 
delivered to determine whether the service delivery actions are 
consistently incorporated across the nation. Moreover, federal and 
state officials do not know whether FSNE services are provided to food 
stamp recipients, the original intended beneficiaries of the services.

Federal FSNE officials stated that local FSNE educators have the option 
of conducting individual needs assessments or of assessing the needs of 
larger targeted populations. However, FNS does not provide standard 
needs assessment tools. In some cases, according to the same officials, 
local FSNE educators are able to use needs assessment tools they 
developed in their state or locality. In the states we studied, the 
state Cooperative Extension offices that administered EFNEP also 
administered FSNE. In these cases, FSNE used a service delivery model 
similar to EFNEP, which included individual needs assessments using 
either a food behavior checklist or other questionnaire. In California, 
the State Director of EFNEP told us these tools might ask about what 
the participant had eaten in the past 24 hours. FSNE educators reported 
using information from similar assessment tools in Michigan to help 
determine what nutrition education content participants needed and to 
identify what nutrition trends were present in the participant 
community. In some cases, FSNE used paraprofessionals to deliver 
nutrition education services, according to officials from two states.

On the basis of our site visits and conversations with officials, we 
found that FSNE efforts generally tailored most services to the needs 
of a targeted group. For example, Michigan FSNE officials told us their 
educators went to migrant farm communities to hold classes late at 
night, from 9 p.m. to 11 p.m., to accommodate the working and living 
circumstances of migrant families. Similarly, FSNE educators went to a 
Detroit homeless shelter to teach food safety and preparation relevant 
to individuals without stable housing. In California, FSNE officials 
reported that their educators tailored the interventions to meet the 
needs of non-English-speaking participants by providing information and 
giving cooking demonstrations in Vietnamese.

FSNE officials in the states we visited told us FSNE services typically 
came through one-time-only interventions. According to FNS officials, a 
series of classes provided through classroom instruction was not the 
usual form of delivery. Services provided via one-time-only methods can 
include media campaigns and other forms of nutrition education designed 
to reach participants through multiple channels. These efforts may 
incorporate the key service delivery actions, when implemented 
properly. However, federal FNS officials told us states' program plans 
vary widely in their quality and level of detail, and federal FNS 
officials did not have a clear picture of what services local officials 
provided.[Footnote 35]

FNS officials expressed concerns over the rapid growth in FSNE funding 
in recent years, combined with states' broad flexibility in 
implementing the program. In particular, from 1992 to 2002, the federal 
funds dedicated for FSNE services have increased, overall, more than 
for the other programs.[Footnote 36] Moreover, every state FSNE 
provider has at least one approved waiver to allow the provision of 
nutrition education to non-food stamp recipients, according to FNS 
officials. While this waiver permits states to provide services to a 
wider range of low-income individuals and eliminates the administrative 
burden of checking for Food Stamp Program eligibility, it also limits 
any assurance that Food Stamp Program recipients receive FSNE nutrition 
education. In fact, FNS officials recognized that at the state and 
local level Food Stamp Program officials did not rely on, or coordinate 
with, FSNE efforts or officials in any systematic way.

FNS officials said they are currently in the process of proposing 
changes to FSNE to address these issues. One of the proposed changes 
would set clear policies and strategies for the delivery of services. 
This change includes developing a policy framework that describes the 
intended structure, target populations, and key behavior changes that 
FSNE intends to promote among participants. This policy framework would 
also set clear roles for the administrators and stakeholders of FSNE 
services at the federal, state, and local levels. In addition to 
developing this policy framework, FNS is developing systems to 
disseminate resources and technical assistance to support state and 
local FSNE services.

NSLP and CACFP Rely on Team Nutrition to Incorporate the Key Actions, 
and Its Capacity is Limited:

Because NSLP and CACFP do not have resources or formal systems in place 
to provide nutrition education, program officials rely on Team 
Nutrition to promote and facilitate nutrition education. Unlike the 
other programs, NSLP and CACFP do not fund staff to provide nutrition 
education. Program funds are dedicated to the administration, 
preparation, and delivery of nutritious meals in school and child care 
settings. NSLP food service workers are primarily responsible for the 
preparation and delivery of school meals, and CACFP workers may be 
responsible for providing child care as well as meals in day care 
settings. As a result, FNS relies on Team Nutrition to develop and 
disseminate education materials and provide grants and guidance to 
states, and Team Nutrition is dependent upon the extent to which child 
care providers and school personnel find or make time to devote to 
nutrition education.

Team Nutrition, which is supported by staff in FNS headquarters, 
focuses on a broad array of activities intended to build school and 
community support for healthy eating, physical activity, and a healthy 
school nutrition environment.[Footnote 37] By doing this, officials 
told us they hope to influence the complex set of environmental factors 
in schools that affect children's health and their motivation to change 
their behavior.[Footnote 38] Team Nutrition promotes a nutrition 
education curriculum that uses multiple communication channels to 
reinforce positive nutrition messages and encourage students to make 
healthy choices. Officials we spoke with stated that Team Nutrition 
materials are of high quality. The nutrition education materials are 
tailored to the broad needs and interests of the children at specific 
age and grade levels. The materials use simple graphics to present 
complex nutrition messages to broad audiences including students, 
parents, and teachers. In addition, Team Nutrition also provides grants 
to schools to support their efforts to create a healthy school 
environment. However, its financial support for state and local 
activities was limited to 21 new competitive grants totaling about $4 
million in fiscal year 2003.

In schools, teachers are uniquely positioned to provide nutrition 
education, and Team Nutrition materials are designed for them to use. 
However, there is little assurance that these materials systemically 
reach teachers and food service workers at the local level. For 
example, one school food authority official told us she often does not 
distribute Team Nutrition Materials because it is not clear to whom 
they are targeted. In addition, principals, teachers, and other 
officials have stated that teachers focus classroom time almost 
entirely on making sure that students meet state academic standards, 
leaving little time to include subjects or information not included on 
the state academic standards test.[Footnote 39] Moreover, because NSLP 
and CACFP have no systems or infrastructure in place to support 
nutrition education delivery at the local level, nutrition education 
efforts in schools can often depend on the leadership of only a few 
individuals. One California official stated that the NSLP nutrition 
education efforts in one particular school district would immediately 
end if the school teacher leading the efforts were to leave.

Although food service workers in schools have limited time available 
for nutrition education, FNS officials reported that Team Nutrition has 
initiated efforts to further promote nutrition education among food 
service staff. Team Nutrition staff have attended state meetings of 
food service workers and offered to provide local training and 
resources to help these staff further incorporate nutrition education 
into their daily activities. As of February 2004, FNS had more than 100 
requests to conduct the training at local sites.

Regarding CACFP facilities, officials told us a limited amount of 
nutrition education takes place in their program and that children are 
the primary recipients of nutrition education services when they are 
provided. This further limits the nutrition education provided to 
adults and the elderly program participants. In addition, the National 
Food Service Management Institute, whose mission is to provide 
information and services that promote the continuous improvement of 
Child Nutrition Programs, provides information and support for school 
food service and CACFP providers.

Programs Generally Did Not Incorporate Key Nutrition Education 
Evaluation Actions, Leaving Officials with Limited Information about 
Program Results:

The programs we reviewed generally did not fully incorporate the 
monitoring and evaluation actions that are key to performance-based 
management and likely to contribute to successful nutrition education. 
Most of the programs--with the exception of EFNEP--did not 
systematically collect data at the federal level on the types of 
nutrition education services provided, who received these services, and 
the outcomes of the services. Moreover, none of the programs we 
reviewed conducted regular nationwide evaluations of its nutrition 
education efforts, largely because such research can be difficult and 
costly. Despite the lack of regular nationwide evaluations, we 
identified some more limited or smaller-scale evaluations and studies 
of the nutrition education efforts conducted by USDA and others over 
the last 10 years. However, these studies were not of sufficient scope 
or quality to allow us to determine whether the programs have met their 
nutrition education goals. As a result, federal and state officials 
have limited information about the nature of nutrition education, 
potential outcomes of nutrition education efforts, and the impact of 
their investments in nutrition education.

Most Programs Did Not Systematically Collect Data on Nutrition 
Education Services or Recipients:

Most of the programs that provide nutrition education did not 
systematically collect data on nutrition education services or 
recipients at the federal level. For example, WIC does not 
systematically collect data at the federal level on the number and 
characteristics--such as age, gender, or income level--of participants 
receiving nutrition education.[Footnote 40] Nor does it collect data on 
the types of nutrition education provided or the length or frequency of 
nutrition education. Team Nutrition tracks the overall numbers of 
educational materials sent to schools but does not have a mechanism for 
tracking whether and how the materials are used. FSNE requires states 
providing nutrition education to submit some information on the number 
of contacts with people or households and on the services provided, but 
there is wide variation in the types of information provided. Moreover, 
federal officials do not have information about the demographic 
characteristics of FSNE recipients or about whether recipients are also 
food stamp recipients. Nor do they have a system for tracking the 
nationwide frequency of delivery methods such as individual meetings, 
classes, media campaigns, or other means. One FSNE official said that 
while some states may use the EFNEP data-reporting system to collect 
information, FSNE officials do not know how many states use the system 
and do not receive data collected through the system unless states 
choose to include them in their annual plans.

However, EFNEP, the one program we reviewed that focuses primarily on 
nutrition education, regularly collected output data on both services 
and recipients. EFNEP gathers a variety of data, including data on the 
race, ethnicity, gender, and family size of recipients; whether 
nutrition education is provided through group or individual 
instruction; and the number of lessons provided.[Footnote 41] The data 
are collected as part of a performance reporting system developed to 
respond to congressional requests for data on program results. To 
facilitate data collection and to produce tailored federal and state 
reports, the national program office provides state and local offices 
with software to record and analyze client data. Although EFNEP does 
not require states to use the software, almost all of the states 
participating in EFNEP use the software to provide data on services and 
recipients.

Without systematic data on nutrition education services and recipients 
in each program, federal offices receive inconsistent and incomplete 
information about what or how nutrition education is implemented at the 
local level and who is being served. A 1996 USDA report noted that the 
paucity of data on the department's nutrition education efforts was an 
obstacle to effective evaluation of those efforts, and one USDA 
official told us that current data collection and monitoring of the 
nutrition education efforts continue to be limited. However, some Team 
Nutrition officials said they were concerned that requiring states to 
provide detailed data on services and recipients would further reduce 
the limited resources states have for providing services and might 
impose reporting burdens that would discourage states from 
participating in Team Nutrition.

Most Programs Did Not Systematically Collect Outcome Data on Their 
Nutrition Education Efforts:

Most of the programs we reviewed did not systematically collect outcome 
data on their nutrition education efforts.[Footnote 42] For example, 
WIC and Team Nutrition did not systematically collect data on changes 
in the nutrition knowledge or dietary behavior of nutrition education 
recipients.[Footnote 43] While most of the programs we reviewed do not 
require states to provide data on potential outcomes of nutrition 
education, states and localities can choose to collect and assess data 
themselves. But because such data collection is optional, most of the 
programs do not have reliable national outcome data in consistent 
formats. For example, Michigan regularly collects data on FSNE 
participants' nutrition status before and after receiving nutrition 
education in order to track progress toward goals. But FSNE's federal 
office does not require such data from participating states and does 
not have consistent nationwide outcome data.

However, EFNEP programs across the country measured participants' 
nutrition-related knowledge and dietary behavior through a behavior 
checklist and a 24-hour recall of food consumption administered at 
program entry and exit and reported the data to USDA through their 
common software system. EFNEP annually summarizes the outcome data 
reported by the states, including the extent to which the nutrient 
intake of nutrition education recipients changed after receiving 
services.[Footnote 44]

We have noted in past reports that federal programs that are intended 
to influence the behavior of individuals or that provide grants to 
states have particular difficulty producing outcome measures.[Footnote 
45] For example, we have noted that officials faced obstacles in 
developing and implementing outcome measures for WIC nutrition 
education, including difficulties identifying effective measures and 
resource constraints affecting their ability to collect the data. 
However, the lack of reliable and systematic outcome data in most of 
the programs we reviewed limits the potential for ongoing monitoring of 
the nutrition education efforts and for formal national program 
evaluation.

None of the Programs Conducted Regular or Nationwide Impact Evaluations 
of the Nutrition Education Efforts:

None of the programs we reviewed conducted regular nationwide 
evaluations assessing the impact of nutrition education efforts. While 
outcome data alone provide information about apparent program results, 
impact evaluation studies provide stronger evidence that the observed 
changes in outcomes--such as improvements in nutrition knowledge and 
dietary behavior--are in fact the results of the nutrition education 
provided. Without centralized, consistent data on changes in 
participants' knowledge and behavior, program officials will have 
difficulty determining whether nutrition education efforts are meeting 
their goals and holding states accountable for the value of public 
investments.

Nevertheless, evaluating the nationwide impact of nutrition education 
can be challenging because (1) the flexibility and variation within 
each nutrition education effort can make it difficult to assess 
national progress toward common goals, (2) the lack of consistent 
national data makes it difficult to track individual participants' 
progress and to expand the scope of an evaluation beyond one state or 
region, and (3) it is difficult to isolate a program's effects from 
other influences. For example, it may be difficult to determine whether 
changes in nutrient intake following nutrition education in the WIC 
program are due to the education rather than to the food assistance 
itself. In addition, it may be quite challenging to determine to what 
extent environmental factors, such as the availability of fresh fruits 
and vegetables in a particular area, are responsible for differences in 
program impact among states and regions.

Moreover, designing and conducting evaluations that overcome these 
challenges can be costly. For example, one official noted that studies 
that randomly assign participants to receive either nutrition education 
or some other treatment are particularly expensive. USDA officials said 
that they are unable to conduct nationwide evaluations of the nutrition 
education efforts on a regular basis, largely because of limited 
funding. None of the programs we reviewed have funding designated 
specifically for research evaluations of their nutrition education 
efforts. Instead, USDA conducts research on these efforts using funding 
for general research needs. However, the department must balance the 
resources needed for nutrition education research and evaluation with 
competing demands for research on other topics.

Instead of regularly evaluating the impact of nutrition education 
efforts, the programs conduct occasional studies. Team Nutrition 
recently conducted a nationwide evaluation of a comprehensive nutrition 
education demonstration program for students, but program officials do 
not know if and when a future evaluation will be conducted. Officials 
noted that the study consumed about one-half of the total funding that 
otherwise would have been available for Team Nutrition state grants in 
one fiscal year. In addition, researchers in some states conduct 
evaluations of aspects of the USDA nutrition education efforts, but 
such evaluations are sometimes limited in geographic scope and in their 
research designs.

USDA recognizes deficiencies in its current data collection and 
evaluation of nutrition education efforts and has taken steps to 
improve monitoring and evaluation. A 1996 USDA report to the Secretary 
found that "a combination of factors--such as a paucity of data, 
inadequate funding, and a change in expected evaluation outcomes--has 
created a challenging environment for USDA to assess the overall 
effectiveness of its nutrition education activities."[Footnote 46] In 
addition, FNS's 1999 report to Congress stated that "the evaluation 
system for FNS nutrition education is fragmented and minimal, and lacks 
outcome measures."[Footnote 47] Noting that reliable data and 
evaluation are essential to effective nutrition education planning, FNS 
highlighted the need to establish a system for routine data collection 
to improve nutrition education planning, management, and outcomes, as 
well as ongoing investments in evaluation studies.

Since then, USDA has begun taking steps to collect more useful data and 
to improve evaluations of program results. Its efforts to improve FSNE 
data collection include a national review of what and how food 
assistance and nutrition services are being provided and the 
development of a uniform data-reporting system for all states 
participating in FSNE.[Footnote 48] In addition, through efforts 
including studies, workshops, and an interagency working group, USDA 
initiated development of methodology and validation of instruments for 
evaluation of FSNE; funded the development of a methodology for 
evaluating Team Nutrition; and provided grants and technical assistance 
to states to encourage more effective nutrition education assessment, 
among other activities. However, we found that these efforts were 
generally preliminary steps toward improving monitoring and evaluation 
practices.

Available Research Provides Little Information about whether the 
Programs Have Met Their Nutrition Education Goals:

Despite the lack of regular nationwide evaluations, USDA and others 
have conducted some limited or smaller-scale evaluations and studies of 
the nutrition education efforts.[Footnote 49] We reviewed this research 
in order to determine whether the USDA programs were meeting their 
nutrition education goals (see app. II for the programs' nutrition 
education goals). However, the research we reviewed is not of 
sufficient scope and quality to allow us to determine whether the 
programs have met their national nutrition education goals, making it 
difficult for program officials to know whether their efforts have been 
effective.[Footnote 50] We reviewed 20 studies by USDA and others 
conducted over the last 10 years that evaluated nutrition education in 
the USDA programs (see app. I for a description of our method for 
identifying studies and our study review methodology). We eliminated 
five studies with major research design limitations that prevented us 
from concluding that improvements in nutrition knowledge or dietary 
behavior were measured appropriately and were due to the nutrition 
education provided rather than to other factors.[Footnote 51] After 
eliminating the studies with major research design limitations, 15 
studies remained in our review, as shown in table 6 (see app. I for a 
list of these studies).

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

Program: EFNEP; 
Studies reviewed: 10; 
Studies excluded because of major research design limitations: (2); 
Program studies: 7; 
Special intervention studies[A]: 1; 
Total: 8.

Program: FSNE; 
Studies reviewed: 2; 
Studies excluded because of major research design limitations: (1); 
Program studies: 0; 
Special intervention studies[A]: 1; 
Total: 1.

Program: WIC; 
Studies reviewed: 7; 
Studies excluded because of major research design limitations: (2); 
Program studies: 2; 
Special intervention studies[A]: 3; 
Total: 5.

Program: Team Nutrition; 
Studies reviewed: 1; 
Studies excluded because of major research design limitations: (0); 
Program studies: 1; 
Special intervention studies[A]: 0; 
Total: 1.

Program: Total; 
Studies reviewed: 20; 
Studies excluded because of major research design limitations: (5); 
Program studies: 10; 
Special intervention studies[A]: 5; 
Total: 15. 

Source: GAO analysis.

[A] Some of the studies we reviewed assessed the impact of special 
interventions or demonstration programs, such as a specially funded 
effort to increase fruit and vegetable consumption among WIC nutrition 
education recipients, rather than the standard nutrition education 
efforts.

[End of table]

Of these 15 studies, 8 evaluated nutrition education efforts in EFNEP. 
However, 1 of these studies did not assess the impact of standard EFNEP 
services; instead, it assessed the impact of an EFNEP special 
intervention. While such studies may be useful in developing strategies 
to change or strengthen nutrition education, they do not allow us to 
determine whether a program as it currently exists is meeting its 
nutrition education goals. The remaining 7 studies we reviewed found 
that EFNEP improved participants' nutrition knowledge or dietary 
behavior. However, because each of these studies was limited to one 
city or state, they do not allow us to determine whether EFNEP as a 
whole is meeting its goals. Given that states and localities have 
substantial flexibility in implementing nutrition education 
interventions, the program may be meeting its nutrition goals in some 
states or regions and not in others. In addition, most of the EFNEP 
studies do not compare changes in the nutrition knowledge and dietary 
behavior of participants with those of nonparticipants, limiting their 
ability to demonstrate that the observed improvements in knowledge and 
behavior resulted from the EFNEP services.

Finally, the other 7 studies assessed nutrition education in the 
nutrition assistance programs--NSLP and CACFP (through Team 
Nutrition),[Footnote 52] WIC, and FSNE. However, these studies do not 
allow us to determine whether the programs have met their nutrition 
education goals because few evaluate standard nutrition education 
efforts and because results were sometimes mixed. Four of the studies 
assessed the impact of special interventions or demonstration programs 
rather than the standard nutrition education efforts. Of the remaining 
studies, none evaluated FSNE. And while 1 study of Team Nutrition among 
fourth-graders found modest increases in nutrition knowledge and 
motivation,[Footnote 53] we did not identify any other studies that 
could help us determine whether Team Nutrition had met its program 
goals. Finally, we identified 2 studies of standard WIC nutrition 
education, but the results of these were mixed. One multistate study 
found that the nutrition education efforts improved knowledge and 
behavior, while another multistate study found that neither standard 
WIC nutrition education efforts nor a special intervention improved 
knowledge among prenatal participants.

Conclusions:

Over the past few decades, the negative health consequences of poor 
nutrition have grown dramatically in the United States. USDA's 
nutrition education efforts alone cannot be expected to halt the 
growing rate of poor nutrition in the country. However, these efforts 
could make valuable contributions to improving nutrition knowledge and 
positively influencing dietary behaviors among low-income individuals 
and schoolchildren.

While only EFNEP is specifically designed to provide nutrition 
education, the other nutrition assistance programs are uniquely 
positioned to provide nutrition education to a broad range of 
participants. However, USDA faces challenges providing nutrition 
education through these multiple programs and incorporating the key 
actions likely to contribute to success. Moreover, USDA has recognized 
the need for a cross-program integrated approach to nutrition education 
in multiple documents, including its recent budget proposal. However, 
although USDA is taking a number of steps to improve the department's 
nutrition education activities, it does not have an overarching 
strategy for increasing coordination efforts and strengthening the 
linkages across its many nutrition education activities. Without 
strategies for a more unifying approach to designing, delivering, and 
evaluating services across all programs, officials have missed 
opportunities to take advantage of the lessons learned from other 
nutrition education efforts and are less likely to make efficient use 
of limited resources.

In addition, most of the nutrition education efforts did not fully 
incorporate the monitoring and evaluation actions likely to contribute 
to successful nutrition education. Specifically, USDA lacks reliable 
data on what nutrition education is provided, the outcomes of the 
services, and how they impact nutrition knowledge and dietary 
behaviors. Properly developed outcome measures can provide useful 
information to program officials, given limited resources for larger 
program evaluations. USDA has recognized deficiencies in its current 
monitoring and evaluation of certain nutrition education efforts and is 
taking preliminary steps to improve them. However, the agency has not 
developed a comprehensive agencywide strategy for incorporating the 
monitoring and evaluation actions key to successful nutrition 
education. Such a unified strategy could help the department manage the 
costs associated with monitoring. However, without a strategy to ensure 
that programs collect reliable data on services and recipients, share 
lessons learned in measuring outcomes, and conduct periodic 
evaluations, officials will have difficulty holding programs 
accountable for meeting their nutrition education goals. Without 
holding programs accountable, USDA officials will be unable to maximize 
the impact of future investments in nutrition education.

Recommendations for Executive Action:

To help overcome the challenges associated with USDA's nutrition 
education efforts and to help programs incorporate the key actions 
related to successful nutrition education, we recommend that the 
Secretary of Agriculture ensure that the department develop a unifying 
strategy that, at a minimum:

* Identifies ways to improve coordination efforts and strengthen the 
linkages among the nutrition education efforts, which would include 
examining options ranging from more systematically sharing nutrition 
education resources across programs to identifying and promoting 
approaches for federal, state, and local officials to implement cross-
program strategies to more efficiently use existing resources. In 
developing a unifying strategy, the department may need to submit 
requests for program changes to Congress.

* Explores options to collect reliable data on services delivered and 
recipients served, and to identify and disseminate lessons learned. A 
longer-term evaluation strategy could include planning periodic and 
complementary evaluations of the impact of the nutrition education 
efforts to the extent possible, in order to make the most efficient use 
of the resources available for such evaluations.

Agency Comments:

We provided a draft of this report to the U.S. Department of 
Agriculture for review and comment. On April 6, 2004, FNS officials, 
including representatives from each FNS program discussed in the 
report, provided us with their oral comments. The officials were in 
general agreement with the recommendations. However, they expressed 
concern about several elements in the draft report. First, they viewed 
our description of the key actions that are likely to contribute to the 
success of nutrition education as too restrictive because it gave the 
impression that there was only one desirable way to provide nutrition 
education. They pointed out that research supports a variety of 
approaches to providing nutrition education. For example, the FSNE 
program permits both classroom activities as well as broader social 
marketing approaches, which can reach more people at a lower cost per 
person. We agree that various approaches can be used to provide 
nutrition education, as long as the key actions in figure 2 are 
incorporated in some way, and we added language in the report in 
response to this comment.

Second, FNS officials believed that our description in the draft report 
of the extent to which the programs under review incorporated the key 
actions unfairly held their programs to a standard that was not 
appropriate, given the role of nutrition education in the various 
programs, the variety of appropriate approaches to delivering nutrition 
education, and the current funding levels. We agree that nutrition 
education plays a different role in each of the programs and adjusted 
our report to better reflect that reality and to avoid comparing the 
programs with one another.

Third, FNS stated that some of the models for nutrition education are 
much more expensive than others, and we have more fully acknowledged 
this in the report. FNS officials also pointed out that conducting 
large-scale impact evaluations would be a very costly and difficult 
endeavor. We agree with this point and have not recommended that USDA 
conduct numerous large-scale evaluations. Instead, we believe that USDA 
can more carefully develop a longer-term evaluation strategy that 
includes plans to conduct periodic and complementary evaluations of the 
various programs.

Finally, FNS officials raised concerns over our discussion of the 
benefits of program consolidation and the need for more coordination in 
the draft report. They pointed out that each program has its own broad 
mission, and it would be difficult to pinpoint opportunities for 
consolidation. Also, officials highlighted a number of ways that they 
coordinate on nutrition education message, resources, and so forth. In 
response, we included additional examples of coordination. However, 
although FNS has taken measures to increase coordination efforts and 
strengthen linkages between its programs, we believe opportunities 
exist for increased coordination efforts and stronger linkages among 
the FNS programs and between FNS and EFNEP. For example, USDA could 
encourage EFNEP and the FNS programs to take a more systematic approach 
to planning and program development, as well as compiling and sharing 
nutrition education curricula and lessons learned. Coordination at the 
state level also poses ongoing challenges. Our recommendation provides 
the department with flexibility to determine the most appropriate means 
to strengthen coordination and improve linkages.

On April 14, 2004, we also received oral comments from the National 
Program Leader for EFNEP on behalf of CSREES. CSREES agrees with our 
recommendations, and stated that the report provides a balanced and 
useful account of the five key nutrition education programs. CSREES 
also noted that we clearly articulated the similarities and differences 
between the programs, noting the variation in size, longevity, 
administrative oversight, funding, and degree of local adaptation among 
the programs. CSREES also particularly noted the relationship between 
FSNE and the state and local Cooperative Extension Service, stating 
that a substantial portion of FSNE's required 50 percent match comes 
from universities and the Cooperative Extension Service. Also, CSREES 
has taken several steps to enhance the coordination and accountability 
of FSNE when its services are administered through Cooperative 
Extension offices, including providing training to FSNE providers and 
developing a tool to enhance the communication and evaluation of 
nutrition education efforts.

In addition, FNS and CSREES also provided us with technical comments, 
which we incorporated where appropriate.

We will send copies of this report to the Secretary of Agriculture, 
appropriate congressional committees, and other interested parties. In 
addition, the report will be available at no charge on GAO's Web site 
at http://www.gao.gov.

If you or your staff have any questions or wish to discuss this 
material, please call me at (415) 904-2272 or Kay E. Brown at (202) 
512-3674.

David D. Bellis 
Director, Education, Workforce, and Income Security Issues:

[End of section]

Appendix I: Scope and Methodology:

To identify the key components believed to contribute to successful 
nutrition education, we reviewed key research on the topic, reviewed 
GAO reports and other documents on performance-based management, and 
conducted interviews with experts in the field of nutrition 
education.[Footnote 54] Specifically, in our review of nutrition 
education research, we relied primarily on one comprehensive research 
review of 217 nutrition education studies at the recommendation of USDA 
officials and academic nutrition education experts.[Footnote 55] We 
also relied on additional input of several nutrition education experts. 
Finally, we reviewed GAO reports and other documents on performance-
based management in order to identify program design and evaluation 
strategies related to successful program management.

To answer the questions related to USDA's nutrition education efforts 
and program planning elements, we conducted interviews with federal 
officials from each of the five USDA programs, examined program reports 
and studies, and reviewed relevant laws and regulations. We also 
conducted interviews with cognizant state and local officials from each 
of the five programs in three states; we conducted site visits in 
Maryland and California and conducted telephone interviews with 
Michigan officials.We selected these states because they represented a 
range of geographic locations and received a range of funding resources 
for nutrition education. Our observations on the delivery of nutrition 
education are primarily based on our site visits and cannot be 
generalized to the programs nationwide.

To identify recent studies that evaluate nutrition education within the 
five USDA programs we reviewed, we searched relevant databases through 
September 2003, such as Agricola, ABI/Inform, Food Science & 
Technology, Educational Resources Information Center, and National 
Technical Information Service, and reviewed related GAO reports. We 
also spoke with nutrition education experts to identify relevant 
research.While these programs all offer services in addition to 
nutrition education, our report focuses on the nutrition education 
components of the evaluations. In order to focus on recent research on 
the nutrition education components of the USDA programs and to target 
articles for detailed review, we identified studies that met the 
following criteria:

* The document is an original research study or an analysis of research 
data, not only a descriptive study, evaluating nutrition education in 
one or more of the five programs.

* The document has been published in a refereed medium (for example, a 
journal article, book or book chapter, or USDA-issued report).

* The document's publication date is 1994 or later.[Footnote 56]

* The document is in English.

We also asked USDA officials to identify any research assessing whether 
the five programs were meeting their nutrition education goals.We then 
compared the lists they provided with our own list of studies to ensure 
that all studies meeting our criteria were included in our review.

Altogether, 20 items met our criteria for review.Many of the items we 
eliminated were published prior to 1994 and therefore do not satisfy 
our definition of recent studies. Some items were eliminated because 
they were published as reviews or summaries of original research but 
did not include any original research. Other items provide descriptive 
information about nutrition education recipients and staff but do not 
evaluate the nutrition education efforts.

We then conducted detailed reviews of the 20 studies. These reviews 
entailed an evaluation of each study's research methodology, including 
its research design, sampling frame, selection of measures, data 
quality, limitations, and analytic techniques, as well as a summary of 
its major findings. We also assessed the extent to which each study was 
relevant to assessing whether a program was meeting its nutrition 
education goals.

One-quarter (5) of the 20 studies had major research design limitations 
that prevented us from including their conclusions in our report.For 
example, a number of studies included the use of inappropriate 
comparisons and comparison groups, and some studies failed to analyze 
data collected both before and after nutrition education was provided. 
For example, one study of WIC nutrition education in New Mexico was 
based on data collected after, but not before, nutrition education was 
provided, allowing a comparison of different delivery methods but not 
an evaluation of overall effectiveness. A study of FSNE in Texas used 
pretest data collected retrospectively, at the same time as post-test 
data, limiting the validity of the data. After eliminating the studies 
with major research design limitations, 15 studies remained in our 
review, as listed in table 7.

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

WIC Studies: Feldman, Robert H. L., Dorothy Damron, Jean Anliker, 
Michael Ballesteros, Patricia Langenberg, Carlo DiClemente, and Stephen 
Havas. "The Effect of the Maryland WIC 5-A-Day Promotion Program on 
Participants' Stages of Change for Fruit and Vegetable Consumption." 
Health Education & Behavior 27:5 (October 2000):649-663.

WIC Studies: Fox, Mary Kay, Nancy Burstein, Jenny Golay, and Cristofer 
Price. WIC Nutrition Education Assessment Study: Final Report. 
Alexandria, Virginia: Abt Associates Inc. for the U.S. Department of 
Agriculture, Food and Nutrition Service, 1998.

WIC Studies: Havas, Stephen, Jean Anliker, Dorothy Damron, Patricia 
Langenberg, Michael Ballesteros, and Robert Feldman. "Final Results of 
the Maryland WIC 5-A-Day Promotion Program." American Journal of Public 
Health 88:8 (1998): 1161-1167.

WIC Studies: Randall, Bonnie, Kim Sprague, David B. Connell, and Jenny 
Golay. WIC Nutrition Education Demonstration Study: Child Intervention. 
Alexandria, Virginia: Abt Associates Inc. for the U.S. Department of 
Agriculture, Food and Nutrition Service, 2001.

WIC Studies: Randall, Bonnie, Kim Sprague, David B. Connell, and Jenny 
Golay. WIC Nutrition Education Demonstration Study: Prenatal 
Intervention. Alexandria, Virginia: Abt Associates Inc. for the U.S. 
Department of Agriculture, Food and Nutrition Service, 2001.

WIC Studies: Joy, Amy Block, Nancy Feldman, Mary Lavender Fujii, Linda 
Garcia, Mark Hudes, Rita Mitchell, Sybille Bunch, and Diane Metz. "Food 
Stamp Recipients Eat More Vegetables after Viewing Nutrition Videos." 
California Agriculture 53: 5 (September-October 1999): 24-28.

WIC Studies: The Story of Team Nutrition: Pilot Study Outcome Report. 
Alexandria, Virginia: Prospect Associates and Westat for the U.S. 
Department of Agriculture, Food and Nutrition Service, 1998.

WIC Studies: Arnold, Catherine Greenwald, and Jeffery Sobal. "Food 
Practices and Nutrition Knowledge after Graduation from the Expanded 
Food and Nutrition Education Program (EFNEP)." Journal of Nutrition 
Education 32:3 (May-June 2000): 130-138.

WIC Studies: Brink, Muriel S., and Jeffery Sobal. "Retention of 
Nutrition Knowledge and Practices among Adult EFNEP Participants." 
Journal of Nutrition Education 26:2 (March-April 1994): 74-78.

WIC Studies: Burney, Janie, and Betsy Haughton. "EFNEP: A Nutrition 
Education Program that Demonstrates Cost-Benefit." Journal of the 
American Dietetic Association 102 (2002): 39-45.

WIC Studies: Cox, Ruby Hurley, Maria Carmen Rita V. Gonzalez-Vigilar, 
Mary Ann Novascone, and Irma Silva-Barbeau. "Impact of a Cancer 
Intervention on Diet-related Cardiovascular Disease Risks of White and 
African-American EFNEP Clients." Journal of Nutrition Education 28:4 
(July-August 1996): 209-218.

WIC Studies: Dollahite, Jamie, and Michelle Scott-Pierce. "Outcomes of 
Individual vs. Group Instruction in EFNEP." Journal of Extension 41:2 
(April 2003).

WIC Studies: Luccia, Barbara H. D., Mary E. Kunkel, and Katherine L. 
Cason. "Dietary Changes by Expanded Food and Nutrition Education 
Program (EFNEP) Graduates Are Independent of Program Delivery 
Method."Journal of Extension 41:3 (June 2003).

WIC Studies: Rajgopal, Radhika, Ruby H. Cox, Michael Lambur, and Edwin 
C. Lewis."Cost-Benefit Analysis Indicates the Positive Economic 
Benefits of the Expanded Food and Nutrition Education Program Related 
to Chronic Disease Prevention." Journal of Nutrition Education and 
Behavior 34:1 (January-February 2002): 26-37.

WIC Studies: Wessman, Cory, Connie Betterley, and Helen Jensen. "An 
Evaluation of the Costs and Benefits of Iowa's Expanded Food and 
Nutrition Education Program (EFNEP): Final Report."Iowa State 
University Extension, Ames, Iowa, 2000.

Source: GAO analysis.

[End of table]

[End of section]

Appendix II: Nutrition Education Goals of Key USDA Programs:

Program: EFNEP; Nutrition education goals: To assist low-income 
families and youths in acquiring the knowledge, skills, attitudes, and 
changed behavior necessary for nutritionally sound diets, and to 
contribute to their personal development and the improvement of the 
total family diet and nutritional well-being.

Program: WIC; Nutrition education goals: To (1) stress the relationship 
between proper nutrition and good health with special emphasis on the 
nutritional needs of pregnant, postpartum, and breast-feeding women; 
infants; and children under 5 years of age; and raise awareness about 
the dangers of using substances during pregnancy and while breast-
feeding; and (2) assist the individual who is at nutritional risk in 
achieving a positive change in food habits, resulting in improved 
nutritional status and in the prevention of nutrition-related problems 
through optimal use of supplemental foods and other nutritious foods.

Program: FSP; Nutrition education goals: To provide educational 
programs that increase, within a limited budget, the likelihood of food 
stamp recipients making healthy food choices and choosing active 
lifestyles consistent with the most recent advice reflected in the 
Dietary Guidelines for Americans and the Food Guide Pyramid.

Program: NSLP; Nutrition education goals: CACFP and NSLP do not have 
explicit nutrition education goals.However, both programs use materials 
developed and disseminated by USDA's Team Nutrition initiative, which 
has the goal of improving children's lifelong eating and physical 
activity habits by using the principals of the Dietary Guidelines for 
Americans and the Food Guide Pyramid. In addition, NSLP encourages 
schools to use the school food service program to teach students about 
good nutrition practices.

Program: CACFP.

Source: USDA.

[End of table]

[End of section]

Appendix III: GAO Contacts and Staff Acknowledgments:

GAO Contacts:

Kay E. Brown (202) 512-3674 (brownke@gao.gov) Katrina Ryan (415) 904-
2114 (ryank@gao.gov):

Staff Acknowledgments:

In addition to the individuals named above, Peter Rumble, Marissa 
Jones, Michelle Verbrugge, Peter Bramble, William R. Chatlos, Luann 
Moy, Daniel Schwimer, and Corinna Nicolau made key contributions to 
this report.

FOOTNOTES

[1] The data reported in the CDC study came from Ali Mokdad et al., 
"Actual Causes of Death in The United States, 2000" JAMA; Mar 10, 2004; 
291, 10; Health Module p. 1238.

[2] "Children's Nutrition and Learning," ERIC Digest, ED369579, June 
1994.

[3] For the purposes of this report, nutrition education is defined as 
any set of learning experiences designed to facilitate the voluntary 
adoption of eating and other nutrition-related behaviors conducive to 
health and well-being.

[4] The USDA also provides nutrition education in a few other programs, 
such as the Food Distribution Program on Indian Reservations and the 
Commodity Supplemental Food Program. However, we did not include these 
programs in our review because they do not receive as large a share of 
overall federal program funds as the programs we review in this report. 


[5] Two of the programs--NSLP and CACFP--rely primarily on an 
initiative called Team Nutrition to support their USDA-sponsored 
nutrition education efforts. Team Nutrition funds the development and 
dissemination of nutrition education materials for these child 
nutrition programs. 

[6] CSREES has responsibility for research, academic programs, and 
Cooperative Extension, which a USDA official says positions it well for 
the design, delivery, and accountability of nutrition education.

[7] Specifically, in our review of nutrition education research, we 
relied primarily on one comprehensive research review of 217 nutrition 
education studies at the recommendation of USDA officials. See Isobel 
Contento, "The Effectiveness of Nutrition Education and Implications 
for Nutrition Education Policy, Programs, and Research: A Review of 
Research," Journal of Nutrition Education, Vol. 27, No. 6 (December 
1995). We also incorporated information from Dr. Contento's draft 2004 
review of nutrition education research. Regarding GAO reports and other 
documents on performance-based management, we relied on our series of 
reports reviewing implementation of the Government Performance and 
Results Act to identify program design and evaluation strategies 
related to successful program management. For example, see U.S. General 
Accounting Office, Results-Oriented Government: GPRA Has Established a 
Solid Foundation for Achieving Greater Results, GAO-04-38 (Washington 
D.C.: March 10, 2004).

[8] For the purposes of our report, we do not include activities such 
as food safety and budget management instruction in our definition of 
nutrition education. As a result, we did not review EFNEP's food safety 
and food resource management education services, nor did we review the 
nutrition assistance services of WIC, Food Stamps, NSLP, and CACFP. 

[9] Other federal agencies, such as the Department of Health and Human 
Services, the Department of Education, and the Department of the 
Interior, support nutrition education. 

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

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

[12] FNS reimburses 50 percent of states' allowable expenditures on 
nutrition education.

[13] Children from households with incomes at or below 130 percent of 
the federal poverty level are eligible for free meals; those from 
households with incomes between 130 percent and 185 percent of the 
poverty level are eligible for reduced-price meals; and those from 
households above 185 percent of poverty pay full price. Also see U.S. 
General Accounting Office, School Meal Programs: Estimated Costs for 
Three Administrative Processes at Selected Locations, GAO-02-944 
(Washington D.C.: September 25, 2002).

[14] USDA intended Team Nutrition to work in conjunction with the 
Nutrition Education and Training (NET) Program in an effort to improve 
the nutrition and eating environment of schools and day care centers. 
NET helped provide the manpower and resources needed for state and 
local officials to coordinate child nutrition programs with nutrition 
education activities in schools and child care centers. However, 
funding for the NET program has not been appropriated since fiscal year 
1998. Team Nutrition now serves a primary, rather than supportive, role 
in providing nutrition education through NSLP and CACFP. 

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

[16] Social marketing is a private sector marketing model that can be 
adapted to social services, which often makes use of television, radio 
ads, videos, and brochures. These materials by themselves do not 
constitute social marketing; rather, social marketing entails a 
comprehensive program in which these materials are employed as part of 
the tactics to reach a target audience. Social marketing also 
emphasizes the importance of keeping the target audience and network 
partners involved in needs assessment, message development, and 
refinement of messages and delivery strategies.

[17] Research indicates that paraprofessionals must have proper and 
adequate training to deliver nutrition education to be beneficial. 

[18] In addition, the Government Performance and Results Act of 1993 
encourages agencies to measure program performance by determining the 
extent to which program outcomes have been achieved.

[19] For more information on the types and sources of foods in schools 
that compete with the NSLP see Nancy Brenner et al., "Mental Health and 
Social Services: Results from the School Health Policies and Program 
Study 2000," Journal of School Health, Volume 71, Number 7, September 
2001.

[20] Specifically, states are required to demonstrate that at least 50 
percent of the population targeted has a gross household income that is 
at or below 185 percent of poverty. 

[21] USDA also participates in committees that work on nutrition 
education with other federal agencies and departments, including the 
CDC, the National Cancer Institute (NCI), and the Departments of 
Education and Health and Human Services. For example, USDA, CDC, and 
NCI are part of the National 5-A-Day Partnership to formulate national 
strategies and plans to increase the consumption of fruits and 
vegetables.

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

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

[24] U.S. Department of Agriculture, Food and Nutrition Service, 
Promoting Healthy Eating: An Investment in the Future (Alexandria, VA: 
December 1999), ii.

[25] The proposed $2.5 million increase would address the lack of 
funding for cross-program initiatives and the widely varying levels of 
nutrition education within the FNS nutrition assistance programs. Of 
the $2.5 million, $1.5 million would be used to expand the Eat Smart, 
Play Hard nutrition education and promotion campaign and fund the 
development of nutrition promotion materials that could be used in more 
than one program. The remaining $1 million would be used for new 
projects that operate across FNS program boundaries.

[26] See U.S. General Accounting Office, School Lunch Program: Efforts 
Needed to Improve Nutrition and Encourage Healthy Eating, GAO-03-506 
(Washington D.C.: May 9, 2003). In this report, we recommended that the 
Secretaries of Agriculture, Health and Human Services, and Education 
encourage states to identify a focal point in each state to promote 
collaborative efforts that would further develop nutrition education 
activities for the schools.

[27] In 1995 and 1996, FNS approved cooperative agreements to establish 
Nutrition Networks in 22 states. As of 2002, 19 of the original 22 
networks were active and self-sustaining. Additional states are 
creating networks or studying the feasibility of creating networks.

[28] Nutrition Networks comprise state and local government agencies, 
nonprofit organizations, and representatives of private industry. The 
networks use social marketing techniques, such as providing nutrition 
education through public service announcements, using mass media to 
reach food stamp participants, and using researched and tailored 
nutrition education messages.

[29] This method of service delivery--highly focused on the individual 
participant--can be higher in cost than nutrition education that 
focuses on broader groups of participants. 

[30] The core program objectives are set at the national level. 
However, the number of classes offered is at the discretion of the 
local implementing agency.

[31] According to WIC regulations, physicians, registered nurses, 
physician's assistants, or state or local medically trained health 
officials may also provide WIC services.

[32] According to FNS officials, state officials have the flexibility 
to set criteria for their own state to determine what conditions 
constitute high nutritional risk.

[33] Although competing requirements limit the time and resources WIC 
educators are able to devote to nutrition education services, FNS 
officials told us that there is a spending floor for nutrition 
education in WIC, which states cannot go below in providing nutrition 
education services. 

[34] This is consistent with our prior review of the WIC program. In 
the study, we reviewed the services provided by six local WIC agencies, 
which were selected using a set of criteria, and found the length of 
time for nutrition education services ranged from 4 minutes to 17 
minutes per intervention. See U.S. General Accounting Office, Food 
Assistance: WIC Faces Challenges in Providing Nutrition Services, GAO 
02-142 (Washington, D.C.: December 7, 2001).

[35] Although FNS has the ability to reject state plans based on 
noncompliance with federal guidelines, FNS officials told us this does 
not regularly happen.

[36] According to officials, state officials may identify noncash 
resources as a part of the state's match for federal FSNE funds. 
According to officials, the growth in FSNE funds might be due to this 
ability to identify public noncash matching funds and private cash 
donations, as well as a lack of a cap on the amount of matching funds a 
state may identify.

[37] To receive Team Nutrition materials, schools can enroll as a Team 
Nutrition school by affirming their commitment to take the lead in 
making nutritional changes, conducting nutrition education activities 
and events, and using materials from Team Nutrition. In addition, Team 
Nutrition makes certain materials and resources available to all 
schools, including those that have not enrolled as Team Nutrition 
schools, on its Web site.

[38] For example, in addition to developing nutrition education 
materials, FNS officials reported that federal staff from Team 
Nutrition and CDC collaborate on an ongoing basis to develop materials 
that address issues such as offering and promoting nutritious food and 
beverage options in vending machines, school stores, and a la carte 
venues.

[39] Also see GAO-03-506.

[40] While WIC collects data on participants in the overall WIC 
program, the federal office does not have information on the number or 
characteristics of participants who receive nutrition education.

[41] We have not reviewed the quality--including the validity and 
reliability--of data collected by EFNEP.

[42] While outcome data are intended, and generally assumed, to measure 
the results of nutrition education services, they do not necessarily 
include evidence that the observed changes are caused by the nutrition 
education intervention and not by other external factors. 

[43] While WIC collects some data on outcomes of breast-feeding 
education, it does not collect other outcome data on the results of 
nutrition education.

[44] We have not reviewed the validity or reliability of these outcome 
measurement tools. However, one study we reviewed that used EFNEP 
outcome data noted that the reliance on self-reported data may lead 
respondents to provide socially desirable answers to some questions. 
See Catherine Greenwald Arnold and Jeffery Sobal, "Food Practices and 
Nutrition Knowledge after Graduation from the Expanded Food and 
Nutrition Education Program (EFNEP)," Journal of Nutrition Education, 
Volume 32, Number 3, May-June 2000. 

[45] U.S. General Accounting Office, Grant Programs: Design Features 
Shape Flexibility, Accountability and Performance Information, GAO/
GGD-98-137 (Washington, D.C.: June 22, 1998) and U.S. General 
Accounting Office, Food Assistance: Performance Measures for Assessing 
Three WIC Services, GAO-01-339 (Washington, D.C.: February 28, 2001).

[46] U.S. Department of Agriculture, The State of Nutrition Education 
in USDA: A Report to the Secretary (Washington, D.C.: October 1996), 
ii.

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

[48] According to FNS, data that may be collected under the new 
Education and Administrative Reporting System include demographic 
characteristics of participants receiving nutrition education 
benefits, information about state goals, topics covered, outlets, 
education strategies, and resource allocations and use.

[49] In addition to identifying several multistate evaluations of USDA 
nutrition education efforts, we identified more limited studies that 
assessed aspects of the nutrition education efforts.

[50] In order to assess the extent to which USDA nutrition education 
efforts were meeting their goals, we reviewed research that 
specifically evaluated the USDA nutrition education efforts. In 
contrast, the key nutrition education actions we describe in figure 2 
are based on an analysis of research on nutrition education in general. 
Also, some research has assessed the impact of certain nutrition 
assistance programs. See research cited in GAO-02-142 and Phil Gleason 
and Carol Suitor, Children's Diets in the Mid-1990s: Dietary Intake and 
Its Relationship with School Meal Participation (Alexandria, Virginia: 
Mathematica Policy Research Inc. for the U.S. Department of 
Agriculture, Food and Nutrition Service, 2001). However, these studies 
did not isolate the impact of nutrition education efforts from the 
overall nutrition assistance programs. 

[51] Given the methodological challenges of measuring the impact of 
nutrition education services on overall health and well-being, studies 
we reviewed generally measured the impact of these services on 
nutrition knowledge and behavior. 

[52] Because CACFP and NSLP provide nutrition education through Team 
Nutrition, we identified studies that evaluated Team Nutrition rather 
than the two programs. 

[53] This study assessed Team Nutrition efforts that officials said 
were more comprehensive than but generally representative of Team 
Nutrition efforts nationwide. 

[54] Nutrition education experts we interviewed included Tom Baranowski 
of Baylor College of Medicine's Children's Nutrition Research Center, 
Leslie Lytle of the University of Minnesota's Division of Epidemiology, 
Isobel Contento of Columbia University, and officials of the American 
Dietetic Association, the American School Food Service Association, and 
the Society for Nutrition Education, among others. 

[55] Contento. We also incorporated information from Dr. Contento's 
draft 2004 review of nutrition education research.

[56] A substantial number of studies of EFNEP were published prior to 
1994.

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