Nutrition Education: USDA Actions Needed to Assess Effectiveness, Coordinate Programs, and Leverage Expertise

The Centers for Disease Control and Prevention reports that many Americans' diets lack adequate sources of good nutrition and that this contributes to costly chronic health conditions. USDA funds and administers a variety of nutrition education efforts, which aim to help educate Americans on nutrition and improve their dietary choices. GAO was asked to review these efforts.

This report examines the extent to which USDA (1) has information on participation, expenditures, and effectiveness for its nutrition education programs; and (2) coordinates its nutrition education efforts and leverages internal nutrition expertise for these efforts. GAO reviewed relevant federal laws, regulations, guidance, and GAO's prior work on nutrition education and leading practices for collaboration; analyzed USDA data on nutrition education participation in fiscal year 2018 and expenditures in fiscal year 2017, the most recent year with complete data available; and reviewed program evaluations and available outcome data for fiscal year 2018. GAO also interviewed USDA officials and representatives of relevant organizations.

The U.S. Department of Agriculture (USDA) administers five key programs that provide nutrition education and has information on participation, expenditures, and effectiveness for most of these programs. USDA tracks the number of participants in direct education, such as classes and counseling, as well as other measures of program reach. For example, Supplemental Nutrition Assistance Program Education (SNAP-Ed), one of USDA's largest nutrition education programs, served 3.8 million participants through direct education in fiscal year 2018. USDA also collects nationwide expenditure data for all of its nutrition education programs, which totaled nearly $907 million in fiscal year 2017—the most recent year with complete data available. In addition, USDA collects some information on the effectiveness of most of its nutrition education programs; yet information USDA collects from states on SNAP-Ed effectiveness cannot be easily aggregated or reviewed. States provide this information in narrative reports, which hinders USDA's ability to assess the effectiveness of interventions used across the country and determine whether SNAP-Ed is achieving its goals.

USDA does not have a formal coordination mechanism for its nutrition education efforts and does not fully leverage the department's nutrition expertise. According to USDA officials, coordinating nutrition education efforts has not been a priority in recent years, and the department does not have a dedicated individual or entity with leadership responsibility for nutrition education. This has resulted in limited coordination across USDA's nutrition education programs, including programs with similar target populations. GAO previously reported that effective coordination can help reduce overlap and duplication. In its absence, USDA's nutrition education programs are missing opportunities to share information and avoid duplicating efforts. Further, some USDA nutrition experts are not located in agencies or offices overseeing the nutrition education programs, and possibly because of this, program staff consult these experts on a limited basis, if at all. Failing to leverage its internal expertise hinders USDA's development of nutrition education materials that are informed by the latest nutrition guidance and research and may reduce the effectiveness of these efforts.

GAO is making three recommendations to USDA, including that USDA improve how it gathers information on SNAP-Ed effectiveness, develop a formal mechanism for coordinating nutrition education across the department, and take steps to fully leverage the department's nutrition expertise for its nutrition education efforts. USDA generally agreed with GAO's recommendations.

According to the Centers for Disease Control and Prevention (CDC),  many Americans’ diets lack adequate sources of good nutrition. Poor  nutrition contributes to costly chronic health conditions, including heart  disease and some cancers, and in 2017, these two conditions were the  leading causes of death in the United States, according to the CDC. The  U.S. Department of Agriculture (USDA) oversees nutrition assistance  programs and funds and administers a variety of nutrition education  efforts, which aim to educate Americans on nutrition and improve their  dietary choices. For example, USDA provided about $433 million in  Supplemental Nutrition Assistance Program Education (SNAP-Ed) federal  grants to states in fiscal year 2019 to improve the likelihood that those  eligible for the Supplemental Nutrition Assistance Program (SNAP) will  make healthy food and physical activity choices. In addition, USDA  develops dietary guidance and conducts and compiles nutrition-related  research and information for the general public.

We last reviewed USDA’s nutrition education efforts in 2004 and found  that USDA faced challenges coordinating its efforts across the  department. At that time, we recommended that USDA develop a  unifying strategy to improve coordination efforts and strengthen the  linkages among these efforts. Although USDA previously took steps to  respond to our recommendation, recently there has been interest in the  level of coordination among USDA’s nutrition education programs.  Specifically, the Agriculture Improvement Act of 2018 (Farm Bill), which  was signed into law on December 20, 2018, requires USDA to submit an  annual report to Congress that includes an evaluation of the level of  coordination between USDA’s nutrition education programs. In light of the  role of these efforts in supporting public health, you asked us to review  USDA’s nutrition education efforts.

This report examines the extent to which USDA (1) has information on  participation, expenditures, and effectiveness for its nutrition education  programs; and (2) coordinates its nutrition education efforts and  leverages internal nutrition expertise for these efforts. In addition to  SNAP-Ed, we focused our review on four other federal programs that  provide nutrition education: the Expanded Food and Nutrition Education  Program (EFNEP), the Special Supplemental Nutrition Program for  Women, Infants, and Children (WIC), Team Nutrition, and the Food  Insecurity Nutrition Incentive (FINI) Grant Program. Among USDA  programs that provide nutrition education, four of these received the  greatest amount of federal funding for nutrition education in fiscal year  2018—WIC, SNAP-Ed, EFNEP, and Team Nutrition. In addition, we  included FINI because its goal is to incentivize healthy eating and it is a  grant program in which nutrition education can be a component.

To address both of our research objectives, we reviewed relevant federal  laws, regulations, and guidance; as well as our prior work on USDA  nutrition education efforts and leading practices for collaboration. We  interviewed officials from relevant USDA agencies, including the Food  and Nutrition Service (FNS), the National Institute of Food and Agriculture  (NIFA), and other USDA agencies overseeing nutrition-related research  and guidance. In addition, we interviewed officials from the seven FNS  regional offices and representatives of selected organizations  knowledgeable about USDA nutrition education efforts, including some  involved in the implementation of nutrition education efforts. We  assessed USDA’s efforts to collect information on its nutrition education  programs, coordinate its nutrition education efforts, and leverage internal  nutrition expertise against the Standards for Internal Control in the  Federal Government.

In addition, to address the first objective, we reviewed USDA research on  nutrition education program effectiveness issued within the last 10 years,  and analyzed USDA data on nutrition education participation in fiscal year  2018 and nationwide expenditures in fiscal year 2017, the most complete  data available as of April 2019. When data were unavailable on program  participation, we analyzed proxy measures for program reach, including  data on the volume of nutrition education materials disseminated, the  online views and downloads of nutrition education materials, and the  number of participants offered nutrition education. To assess the reliability  of these data, we interviewed USDA officials and reviewed relevant  documentation. We determined these data to be sufficiently reliable to  identify the numbers of participants served or offered services, materials  provided, and nationwide expenditures for SNAP-Ed, EFNEP, WIC, Team  Nutrition, and FINI. For a more detailed description of our methods, see  appendix I.

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

Administration of USDA’s Nutrition Education Programs

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

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

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

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

Structures, Target Populations, and Types of Education

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Coordination of Nutrition Education Efforts Is Limited

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

USDA Has Not Fully Leveraged Its Expertise for Nutrition Education

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

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

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

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

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

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

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

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

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

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

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

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

Appendix I: Objectives, Scope, and Methodology

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

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

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

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

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

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

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

Program Evaluations and Additional Program Data

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

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

Interviews with Land-Grant University Representatives

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

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

Appendix III: GAO Contact and Staff Acknowledgments

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

Poor nutrition contributes to costly chronic diseases that are among the leading causes of death for Americans. USDA's nutrition education efforts aim to educate Americans on nutrition and improve their dietary choices.

However, USDA lacks information on whether one of its largest nutrition education programs is meeting its goals. Further, USDA officials who work on nutrition education programs aren't always coordinating with one another or consulting other USDA nutrition experts, including those who develop dietary guidance—which reduces the effectiveness of these efforts.

We recommended actions USDA could take to address these issues.