June 4, 2013
Branch Chief, State Administration Branch Program
Accountability and Administration Division
Supplemental Nutrition Assistance Program
Food and Nutrition Service, USDA
3101 Park Center Drive
Alexandria, VA 22302
Re: RIN 0584-AE07 (Supplemental Nutrition Assistance Program: Nutrition Education and Obesity Prevention Grant Program)
Dear Ms. Duffield:
The Academy of Nutrition and Dietetics (the "Academy"), formerly the American Dietetic Association, is pleased to comment on the interim rule "Supplemental Nutrition Assistance Program [SNAP]: Nutrition Education and Obesity Prevention Grant Program;" (RIN 0584-AE07) published April 5, 2013. The Academy is the world's largest organization of food and nutrition professionals, with more than 75,000 members comprised of registered dietitian-nutritionists (RDNs), registered dietitians (RDs), dietetic technicians, registered (DTRs), and advanced-degree nutritionists. Every day we work with Americans in all walks of life, from prenatal care through old age, providing nutrition care and conducting nutrition research. RDNs, RDs, and DTRs are currently involved in a variety of successful food and water insecurity programs at local, state, and federal levels. We are committed to improving the nation's health and meeting nutrition needs through the lifecycle and work to ensure that all Americans have access to a healthy, safe food supply by leading efforts to reduce food deserts and food swamps, increasing participation in nutrition education programs, and collaborating with industry to help develop nutritious food products.
The Academy supports the United States Department of Agriculture Food and Nutrition Service's (FNS) interim rule codifying a new framework for the provision and funding of effective nutrition education and obesity prevention programs to SNAP recipients and similar low-income individuals (collectively, "SNAP-Ed"). The proposed reforms in the interim rule add flexibility and efficiencies to the program, ensure rigorous oversight, and facilitate a comprehensive approach to behavioral change among participants.
Crisis of Food Insecurity in America
Food insecurity in America is a serious public health and economic problem. Of the 316 million people living in America,1 50 million Americans, including 8.6 million children were food insecure in 2011.2 These rates have substantially increased over the last two decades. In 1998, 10.2 percent Americans lived in food-insecure households; in 2011, 14.9 percent of U.S. households were food insecure at some time. 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. A 2007 study found that hunger (and related costs of mental and physical illness and stunted educational attainment) resulted in an annual $90 billion cost burden.3 Obesity—a precursor to heart disease, stroke, type 2 diabetes and cancer—cost the U.S. $147 billion annually in 2008 dollars.4 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.5
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.6 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.7 Adequate funding for food and nutrition assistance programs 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.8 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.9 Pursuant to the reforms of the interim rule, SNAP and SNAP-Ed can effectively address the problem of food insecurity in America while being mindful of the best use of resources and participants' budgetary constraints. For too many Americans, SNAP provides—rather than merely supplements—their caloric intake, so education to maximize the healthiness of food choices is critical.
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.10 Healthy nutrition and physical activity messaging through SNAP-Ed reaches a huge audience. The subset of programs administered by land grant universities in 2010 alone reached 4.5 million SNAP-Ed participants via 54.6 million direct education (i.e., generally face-to-face) interactions and 35.8 million valuable indirect education interactions using educational media such as billboards or TV/radio healthy eating messages.11 The entirety of indirect marketing is far greater and is a critically valuable strategy; FNS should work to assess measurable outcomes for all indirect nutrition education. 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.12
- 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.13
- 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.14
- 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.15
- The JNEB recently 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.16
The interim rule codifies reforms consistent with existing FNS SNAP-Ed Plan Guidance and meets the funding transition period timeline mandated by the Healthy, Hunger-Free Kids Act of 2010 (HHFKA). The interim rule will enable states to use nutrition education approaches that make strides in achieving several of the most important items on the SNAP to Health "Menu of Recommendations," including "[e]ncourag[ing] public and private support for programs that incentivize the purchase and/or reduce the price of nutrient-dense foods in grocery stores and farmers' markets" and "[s]trengthen[ing] stocking standards for a variety of healthy foods (e.g., fruits and vegetables) in order to be certified as a SNAP retailer."19 These reforms encourage provision of behaviorally- and environmentally-focused, evidence-based nutrition education and obesity prevention programs and facilitate streamlined continuity of funding and programs across multiple years. However, the Academy is concerned that these reforms may blur the focus on the crisis of food insecurity among participants, and encourages FNS to renew its commitment to ensuring sufficient provision of nutritious foods to this population.
The HHFKA and the interim rule ensure that integrity of the SNAP-Ed program is sound. Its operation and effectiveness will be improved by improved access to nutrition education funding for all states and the statutory formula to allocate funds to States based on SNAP participation rates. The transition period in the interim rule is sufficient to help States put program infrastructure in place and considers appropriate costs and time associated with building new infrastructure in previously under-participating states. Rigorous program oversight will ensure integrity of funds, program effectiveness regarding outcomes, and thus the program itself.
Improved Flexibility and Targeting
Broadening the definition of SNAP-eligible participants to align with other Federal assistance programs enables the program to best target and reach the audience Congress intended. The interim rule appropriately provides additional flexibility to States to conduct evidence-based and efficient programming by reducing administrative burden. Academy members note that the limited definition of who can participate or locations where nutrition education may be provided have been issues within the field and has resulted in many low-income, needy individuals not receiving nutrition education services. For that reason, the Academy agrees with FNS that alternative targeting methodologies that address concerns about increasing the reach of nutrition education will facilitate administration of the program and the best, broadest identification of target participants. Increasing reach through worksites, churches, retail food stores, community spaces, and value-oriented restaurants is critical to achieving an integrated, successful strategy for nutrition education. The interim rule's added flexibility will extend reach to target populations without artificially constraining effective large-scale or "upstream" programs simply because they might inadvertently reach additional people who are ineligible due to somewhat higher income. The Academy also suggests adding allowable state-specific criteria, including higher cost of living areas; demographics such as age, ethnicity, and education; and the use of certain larger-scale population lines such as school districts or city segments (e.g., ANC Single Member Districts in Washington, D.C. or Neighborhood Planning Unites in Atlanta, GA) with buffer zones near qualifying census tracks or institutional locations used by SNAP and other means-tested program participants. FNS should then share or make available the approved targeting methods with regional and state SNAP staff. Increased flexibility in strategies is also critical if SNAP-Ed is to serve SNAP audiences across the lifespan, particularly older adults who have been chronically underserved by SNAP and represent a growing population in many states.
The interim rule's definitions and the ability for States to propose implementing annual or multi-year SNAP-Ed Plans (of up to three years) provide States with greater flexibility, including the ability for SNAP-Ed providers to make multi-year hiring and programmatic decisions. The enhanced flexibility is likely to improve coordination of services, targeted populations, and projects among differently funded programs and entities throughout States once funding is stabilized and actually appropriated in accord with the HHFKA. The Academy encourages FNS to allow greater flexibility in how SNAP-Ed funds may be used by states for subsequent evaluative purposes.
Comprehensive Approach to Behavior Change to Include Obesity Prevention
The Academy believes that long-term interventions for the entire socioecological model are needed to achieve food and nutrition security in the United States. Social capital—social trust and community norms and networks that facilitate collective action—appears especially important to end food insecurity in the United States.20 The interim rule is poised to encourage long-term interventions and enhance social capital, and the Academy recommends that FNS invest in technical assistance and training for regional and state SNAP staff to fully integrate comprehensive approaches to behavior change in state plans.
The HHFKA changed SNAP-Ed significantly with its added, specific focus on obesity prevention programs, including what the Academy hopes will be a greater emphasis on physical activity through community and public health approaches. It allows for a wider range of dynamic evidence-based and practice-based intervention strategies in an evolving field. The interim rule's support of multi-level community and public health approaches through collaboration and coordination with public and private interventions will allow for additional programmatic activities and topics. Increased flexibility in strategies to allow for expanded delivery of nutrition education is critical for this population where studies show a substantial number of participants—particularly women—are obese.21
Additional, Continuing Research and Analysis
The Academy believes that continued research is needed to further understand the benefits of federal and community food and nutrition assistance programs and their influence on both nutrition and non–nutrition-related outcomes. FNS should show and share which nutrition education and obesity prevention activities have either been demonstrated to work or show significant promise. The Academy encourages USDA to continue investing in valuable research such as the Wave I and Wave 2 education and evaluation studies. In addition, FNS should provide, through the Regional Offices, specific recommendations and examples of effective State-level administration of nutrition education grants and peer-review systems.
Mary Pat Raimondi, MS RDN
Vice President, Strategic Policy and Partnerships
Pepin Andrew Tuma, Esq.
Director, Regulatory Affairs
1 United States Census. Population clock. Web site: http://www.census.gov/main/www/popclock.html. Accessed June 2, 2013.
2 Food Security Status of U.S. Households in 2011. United States Department of Agriculture. Economic Research Service. Web site: http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/key-statistics-graphics.aspx. Accessed on June 2, 2013.
3 Brown, L., Shepard, D. Martin, T. Orwat, J. The Economic Burden of Domestic Hunger: Estimated Annual Burden to the United States. Sodexho Foundation, in partnership with the Public Welfare Foundation and Spunk Fund, Inc. June, 2007 Website: http://www.sodexofoundation.org/hunger_us/Images/Cost%20of%20Domestic%20Hunger%20Report%20_tcm150-155150.pdf. Accessed June 2, 2013.
4 Centers for Disease Control and Prevention, Overweight and Obesity Facts, 2012. Website: http://www.cdc.gov/obesity/data/adult.html. Accessed June 2, 2013.
5 Trust for America's Health, F as in Fat: How Obesity Threatens America's Future 2012. Website: http://healthyamericans.org/report/100/. Accessed June 2, 2013.
6 Holben DH. Position of the American Dietetic Association: Food insecurity in the United States. J Am Diet Assoc. 2010; 110: 1368-1377.
7 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.
8 Holben DH. Position of the American Dietetic Association: Food insecurity in the United States. J Am Diet Assoc. 2010; 110: 1368-1377.
9 Holben DH. Position of the American Dietetic Association: Food insecurity in the United States. J Am Diet Assoc. 2010; 110: 1368-1377.
10 7 CFR Part 272.
11 Supplemental Nutrition Assistance Program Education through the Land-Grant University System for FY 2010: A Retrospective Review. Website: http://msucares.com/archive/2012/snap-ed/snapedreport_jan16web.pdf. Accessed June 2, 2013.
12 Foster et al. A Policy-Based School Intervention to Prevent Overweight and Obesity. Pediatrics Vol. 121, No. 4, April 2008
13 2011 Adult/Senior Track – Pennsylvania SNAP-Ed Evaluation Results. Website: http://www.panutritiontracks.org/public/documents/FY11Post-PreReport.pdf. Accessed June 2, 2013.
14 Koszewski, W. The Impact of SNAP-Ed and EFNEP on Program Graduates 6 Months after Graduation. Journal of Extension, 2011. 49(5).
15 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.
16 Foerster SB, Gregson J. From the Network for a Healthy California. J Nutr Educ Behav. 2011;43(4 Suppl 2):S48-52.
17 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.
18 Zandi M. The Economic Impact of the American Recovery and Reinvestment Act. Website: http://www.economy.com/
19 Center for the Study of the Presidency and Congress. SNAP to Health: A Fresh Approach to Strengthening the Supplemental Nutrition Assistance Program. Website: http://www.snaptohealth.org/wp-content/uploads/2012/10/CSPC-SNAP-Report.pdf at 9. Accessed June 2, 2013.
20 Martin KS, Rogers BL, Cook JT, Joseph HM. Social capital is associated with decreased risk of hunger. Social Sci Med. 2004;58: 2645-2654. See also, Woolcock M. The place of social capital in understanding social and economic out- comes. Can J Policy Res. 2001;2:11-17.
21 Ohri-Vachaspati et al, Policy Considerations for Improving the Supplemental Nutrition Assistance Program: Making a Case for Decreasing the Burden of Obesity, Website: http://www.azdhs.gov/phs/bnp/nupao/ documents/SNAP_White_Paper_12-14-11l.pdf. Accessed June 2, 2013.