September 25, 2017
State Administration Branch
Program Accountability and Administration Division
Supplemental Nutrition Assistance Program
U.S. Department of Agriculture, Food and Nutrition Service
3101 Park Center Drive, Room 821
Alexandria, VA 22302
Re: Proposed Collection; Comment Request-Supplemental Nutrition Assistance Program Education (SNAP-Ed) Toolkit Intervention Submission Form and Scoring Tool (OMB Number 0584-NEW)
Dear Ms. Mays,
The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to comment on the Food and Nutrition Service (FNS) of the United States Department of Agriculture's (USDA's) comment request regarding its "Proposed Collection; Comment Request-Supplemental Nutrition Assistance Program Education (SNAP-Ed) Toolkit Intervention Submission Form and Scoring Tool." Representing over 100,000 registered dietitian nutritionists (RDNs),1 nutrition dietetic technicians, registered (NDTRs),2 and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States committed to a world where all people thrive through the transformative power of food and nutrition, enabled in part through the development and delivery of effective, efficient SNAP-Ed interventions.
The Academy supports FNS's proposed information collection for additional effective nutrition education and obesity prevention interventions with SNAP recipients and similar low-income individuals (collectively, "SNAP-Ed") to be reviewed for inclusion in the SNAP-Ed Strategies & Interventions: An Obesity Prevention Toolkit for States (the "Toolkit") (https://snapedtoolkit.org). In short, SNAP-Ed works. These evidence-based interventions encourage and maintain healthy behaviors, have been shown to improve health and are demonstrated to be economically sound investments. The Academy supports utilizing the proposed uniform method to newly include in the Toolkit evidence-based nutrition education approaches that work in sync with one another, with each reaching the intended populations, achieving the intended purposes, and working in intended venues.3
A. Crisis of Food Insecurity in America
Food insecurity in America is a serious public health and economic problem. Of the 325 million people living in America,4 41.2 million Americans, including 6.5 million children were food insecure in 2016.5 These rates have essentially remained the same since 2015. However, a statistically significant decline was seen, with 14% of Americans considered food-insecure in 2014 to 12.7% in 2015. In 2000, 10.5% Americans lived in food-insecure households; in 2011, 14.9% of U.S. households were food insecure at some time. A cumulative decline from the 2011 rates has continued in 2016. Rising rates of childhood obesity and diabetes are signs that a population can be "well-fed" despite being poorly nourished.
Pure economic costs to the nation from food insecurity are also staggering. In an extensive assessment of peer reviewed research, it was estimated that hunger (and related costs of mental and physical illness and stunted educational attainment) resulted in an annual $160 billion cost burden.6 Obesity—a precursor to heart disease, stroke, type 2 diabetes and cancer—cost the U.S. $147 billion annually in 2008 dollars.7 By 2030, medical costs associated with obesity are expected to increase by at least $48 billion annually; medical costs coupled with costs associated with reduced economic productivity could total between $390 billion to $580 billion.8
The Academy believes that access to food is a basic human need and fundamental right. Food security is the linchpin of healthful living and must be achieved in the United States to improve the health of its citizens and residents.9 Because households undoubtedly experience job transitions, layoffs, and other disruptions regardless of the economy, robust safety net programs are vital to helping U.S. citizens and residents achieve food and nutrition security.10 Adequate funding for food and nutrition assistance programs and the education initiatives supporting them is vital to maintaining the integrity of the nation's nutrition safety net.
It is the position of the Academy of Nutrition and Dietetics that systematic and sustained action is needed to achieve food and nutrition security for all in the United States. To eliminate food insecurity, a variety of interventions are needed, including adequate funding for and increased utilization of food and nutrition assistance programs, inclusion of food and nutrition education in such programs, and innovative programs that promote and support individual and household economic self-sufficiency.11 The Academy knows that adequate funding for and increased use of food and nutrition assistance programs, particularly those already incorporating nutrition education, is particularly important to improve the dietary outcomes related to food insecurity. Nutrition education should be an important component of all nutrition assistance programs. In addition, developing community partnerships and networks that build local food systems are crucial.12 For too many Americans, SNAP provides—rather than merely supplements—their caloric intake, making education to maximize the healthiness of food choices even more critical.
B. Nutrition Education Works
The goal of SNAP-Ed is to improve the likelihood that persons eligible for SNAP will make healthy food choices within a limited budget and choose physically active lifestyles consistent with the current Dietary Guidelines for Americans and MyPlate.13 Healthy nutrition and physical activity messaging through SNAP-Ed reaches a huge audience. The subset of programs administered by land grant universities in 2015 alone reached 2.5 million SNAP-Ed participants via 13.3 million direct education (i.e., generally face-to-face) interactions and 103 million valuable indirect education interactions using educational media such as billboards or TV/radio healthy eating messages.14
Numerous SNAP-Ed programs have improved health by promoting healthful behaviors:
- A Pennsylvania SNAP-Ed program, as part of a multifaceted approach, has shown a 50% reduction in the incidence of overweight among elementary school students.15
- Pennsylvania senior citizens enrolled in a SNAP-Ed program increased their consumption of dairy products, drank milk in place of another beverage, ate more dark leafy vegetables, planned meals before shopping for groceries, used a shopping list while grocery shopping and improved food safety behaviors.16
- Nebraska graduates of a SNAP-Ed program maintained healthy behaviors (e.g., shopping with a list, using the Nutrition Facts Label to make food choices, decreasing consumption of sugar-sweetened beverages) six months post-graduation.17
- A study published in the Journal of Nutrition Education and Behavior (JNEB) found that the No Kid Hungry campaign's Cooking Matters program, which relies on SNAP-Ed funding, improves participants' food choices, eating habits, cooking skills and food budgeting and shopping practices in the short (three month) and longer (six month) terms.18
- The JNEB published a supplement, entitled “Network for a Healthy California: Evaluation Results of Multi-level Nutrition Education through SNAP-Ed” with ten-year results showing a variety of community approaches among different populations and age groups with the greatest need, together with impressive statewide improvements: for adults who report five+ daily servings of fruits and vegetables: a 91% increase for the poorest, 77% increase for African Americans, 43% for Latinos, and—for the years where they had complete measures—a 47% increase for SNAP adult participants.19
In addition to improving healthful behaviors, nutrition education programs such as SNAP-Ed and another nutrition education program, the Expanded Food and Nutrition Education Program (EFNEP), are also economically sound investments. The economic return of EFNEP, for example, far exceeds the cost, with a return on investment of $9.58 in health care and productivity savings for every $1 spent.20 The economy increases by $1.73 for every $1.00 put into SNAP, with much of that economic gain directly returning to the local community.21 The Academy supports a variety of nutrition education approaches that work in synch with one another and each reaches the intended populations, achieves intended purposes, and works in particular venues.
Multiple government agencies and non-governmental stakeholders working together, including FNS, have recently compiled a cutting-edge set of intervention and evaluation resources to help SNAP-Ed agencies deliver strong, evidence-based interventions to diverse communities, map their progress, and report the results. The Toolkit links to approximately eighty evidence-based interventions that were largely developed through SNAP-Ed funding. The Toolkit is exciting, useful, and novel, and it "reflects a brand new science base for large-scale interventions – especially those using social marketing and policy, systems and environmental change approaches – that is customized to low-resource settings and diverse populations."22
The Academy is pleased to comment that Toolkit Intervention Submission Form and Scoring Tool both have practical utility because together they will allow states to identify interventions that will fit SNAP-Ed grant criteria and increase the selection of these interventions for states. We agree it is essential to verify that intervention tools included in the Toolkit are evidenced-based and effective.
We note that the estimated time burden for the Intervention Submission Form and the Scoring Tool are based upon two and three pilot testers, respectively, and question whether such a small sample enables FNS to derive a reasonable estimate. The burden could potentially be lessened by decreasing the length of the forms or by eliminating or streamlining the open-ended questions, unless the data obtained therefrom is critical in FNS's analysis of whether submitted interventions meet its criteria. We support the existing inclusion of sections on languages, funding source, and material costs. In addition, we suggest FNS consider including additional sections for "senior centers or congregate meal sites" (under "sites") as seniors are a population of focus for SNAP-Ed; participant literacy level; and the burden on the participant of completing the activity or intervention, especially as it relates to collecting outcomes. We also encourage electronic use of the forms and the submission of interventions on a rolling, rather than annual, basis.
Finally, we support efforts to ensure unbiased determination whether to include interventions in the Toolkit, including the scoring step and blinded scoring to reduce reviewer bias. We note that some may find the rubric difficult to follow, requiring additional or specialized training.
The Academy supports FNS's efforts to include additional evidence-based SNAP-Ed interventions meeting its criterial into the Toolkit and offers our assistance for this important initiative. Please contact either Jeanne Blankenship by telephone at 312/899-1730 or by email at email@example.com or Pepin Tuma by telephone at 202/775-8277, ext. 6001 or by email at firstname.lastname@example.org with any questions or requests for additional information.
Jeanne Blankenship, MS, RDN
Vice President, Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics
Pepin Andrew Tuma, JD
Sr. Director, Government & Regulatory Affairs
Academy of Nutrition and Dietetics
1 The Academy recently approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.
2 NDTRs are educated and trained at the technical level of nutrition and dietetics practice for the delivery of safe, culturally competent, quality food and nutrition services. They are nationally credentialed and are an integral part of health care and foodservice management teams. They work under the supervision of a registered dietitian nutritionist when in direct patient/client nutrition care; and often work independently in providing general nutrition education to healthy populations.
3 See, U.S. Congress. House Committee on Agriculture Hearing on "The Past, Present and Future of SNAP: Evaluating Effectiveness and Outcomes in Nutrition Education."(Date: 06/27/2016) Testimony of Susan B. Foerster, MPH. Available from House Committee on Agriculture. Accessed September 20, 2017.
4 United States Census. Population clock. Accessed September 25, 2017.
5 Food Security Status of U.S. Households in 2016. United States Department of Agriculture. Economic Research Service. Accessed on September 25, 2017.
6 Bread for the World Institute. The Cost of Hunger in the United States. Accessed on September 26, 2017.
7 Centers for Disease Control and Prevention, Overweight and Obesity Facts, 2012. Accessed September 26, 2017.
8 Trust for America's Health, F as in Fat: How Obesity Threatens America's Future 2012. Accessed June 2, 2013.
9 Holben DH. Position of the American Dietetic Association: Food insecurity in the United States. J Am Diet Assoc. 2010; 110: 1368-1377.
10 Nord M, Andrews M. Reducing Food Insecurity in the United States: Assessing Progress Toward a National Objective. Alexandria, VA: Economic Research Service, US Department of Agriculture; 2002. Food Assistance and Nutrition Research Report No. 26-2.
11 Holben DH. Position of the American Dietetic Association: Food insecurity in the United States. J Am Diet Assoc. 2010; 110: 1368-1377.
12 Holben DH. Position of the American Dietetic Association: Food insecurity in the United States. J Am Diet Assoc. 2010; 110: 1368-1377.
13 7 CFR Part 272.
14 Supplemental Nutrition Assistance Program Education through the Land-Grant University System for FY 2015: Final Report. Accessed September 26, 2017.
15 Foster et al. A Policy-Based School Intervention to Prevent Overweight and Obesity. Pediatrics Vol. 121, No. 4, April 2008
16 2011 Adult/Senior Track – Pennsylvania SNAP-Ed Evaluation Results. Accessed June 2, 2013.
17 Koszewski, W. The Impact of SNAP-Ed and EFNEP on Program Graduates 6 Months after Graduation. Journal of Extension, 2011. 49(5).
18 Swindle S, Baker SS, Auld GW. Operation Frontline: assessment of longer-term curriculum effectiveness, evaluation strategies, and follow-up methods. J Nutr Educ Behav. 2007;39(4):205-13.
19 Foerster SB, Gregson J. From the Network for a Healthy California. J Nutr Educ Behav. 2011;43(4 Suppl 2):S48-52.
20 Dollahite J, Kenkel D, Thompson CS. An economic evaluation of the expanded food and nutrition education program. J Nutr Educ Behav. 2008;40(3):134-43.
21 Zandi M. The Economic Impact of the American Recovery and Reinvestment Act. Accessed June 2, 2013.
22 Foerster Testimony to House Agriculture Committee, supra at 6.