Nutrition Education: A Strategy in Welfare Reform

Copyright ©  2008  Regents of the University of Minnesota. All rights reserved.

Purpose of Presentation:

The intent of this think piece is (1) to capture the logic and scholarly findings for public and private sector support of nutrition programs in general and nutrition education programs specifically and (2) to build the case for nutrition education as a strategy in welfare reform.

The initial thinking occurred to undergird the work of the NASULGC Board of Human Sciences Committee on Federal Legislation and Appropriations which I chaired in l996. In l995, as chair of the BOHS Welfare Reform Task Force, we found that nutrition education programs were under attack or "reconsideration" by Congress. A defense was needed to argue for their place in the "general welfare" of the people of the U.S. and the responsibility of the federal government according to the U.S. Constitution. In my own state, we needed to develop the proposal for fiscal year 1997 funding of the Minnesota State Food Nutrition Program. We now need the logic to link nutrition education as a strategy in welfare reform.

This version is intended for use by those engaged in state and local public policy as they wrestle with accommodating the new federal legislation of l996, which changed government assistance programs, specifically food stamps and Aid to Families with Dependent Children. The logic could be used by institutions seeking support in their states and localities. It could be used at the federal level in coming years when nutrition programs are again re-examined. Food stamps were only reauthorized for two years in l996. Thus, in l998, the case will again need to be made. This presentation could be used as part of that case.

And finally, I want to acknowledge that I am not a nutritionist. Rather, I am an educator with expertise in family resources and experience in public policy education and an administrator charged with championing "the cause" and with building and making "the case." The references I've included in this paper are not exhaustive on the subject. I've chosen them as a select few that help to build the case for nutrition education as a strategy in welfare reform. I will count on colleagues in nutrition and nutrition education to build on this case and to correct me if any evidence I've used is not adequate. Please consider what I'm offering as a work-in-progress which together we'll improve.

From Welfare to Well-being

In other presentations, along with my colleague, Dr. Jean Bauer, I've tried to build the case for moving the attention of the general public and public policy makers from a focus on "welfare" for "those people" to the well-being of all people.³ I've suggested that with the historic shift in welfare legislation, the opportunity arose for a more comprehensive examination of the well-being of individuals, families, communities and our nation. Some of you may have viewed our broadcast on January 23 or later, via tape. If not, you may still wish to view it as a foundation for understanding welfare reform and well-being. (To order copies of the video, see electronic catalog information for item VH-6787 )

In this presentation, I am focusing on the link between nutrition, nutrition education and the goals of welfare reform: personal responsibility and self-sufficiency.

Nutrition Education: The Link Between the Well-being of Individuals, Families and the Nation

As the United States debates the reform of the welfare of its people, there is a need for the public in general and educators and policy-makers in particular to understand the link between a fundamental physical building block of human beings-nutrition-and the well-being of our country.⁴ Those of you who make your living in nutrition know this link. Many others do not. We must constantly make that case-show the link.

Historical Conditions

Federal food assistance began because of conditions brought on by the Great Depression: the need to stabilize farm prices and incomes and the prevention of hunger while improving the nutritional status of the poor. The link of nutrition to well-being was further reinforced when many World War II draftees failed their physical exams. The federal government's ability to "provide for the common defense" of the country was hampered by the poor physical condition of people who were undernourished. This condition led to the establishment of child nutrition and feeding programs-argued for, established, and often managed by home economists.¹⁹

With the recognition that people were still living in poverty and at-risk of inadequate nutrition, the modern food stamp program began in the l960s with funding through USDA and administration through HHS. Its intent was to extend the resources available to eligible households to purchase food. Along the way, based on the nutrition research of USDA, the Recommended Daily Allowances of nutrients were established and food plans to meet those created.

Because of the risk of poor nutrition and poor health outcomes due to insufficient nutrition during the critical growth and development periods of pregnancy, infancy and early childhood, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) was created. The concept of nutrition risk as a requirement for eligibility for WIC is a unique feature of Public Law 94-105. One risk factor, published in a l996 report of the Institute on Medicine's Committee on Scientific Evaluation of WIC Nutrition Risk Criteria¹⁸ is that posed to people with conditions that predispose them to inadequate nutritional patterns, such as a low level of maternal education and literacy. Thus, based on that risk factor, one component of WIC is nutritional education.

Long before the WIC nutrition education program, Cooperative Extension was teaching nutrition in its programs targeted at people without other access to nutrition research. Nutrition education was a cornerstone of Cooperative Extension as it was established by the Smith-Level Act of l914. Then, in the late l960s, an innovative nutrition education program, EFNEP, created by home economists, was funded through the USDA via the Cooperative Extension Service. The Expanded Food and Nutrition Education Program went beyond the historic home economics nutrition education and was targeted to "at-risk" families with young children, especially those in urban areas not traditionally served by the CES. Its intent was to make behavioral changes at an early and critical stage in a child's life. Funding for the program, which serves over 600,000 families yearly, has fluctuated and hovers around the $100M level, of which $60M is federal and $40M is state and local funds.

Between 1993 and 1996, $72M ($12M federal and $60M state and local) was invested in a collaborative Nutrition Education Initiative between Extension and WIC.

By the l990s, the funds for the Food Stamp Program were allocated to nutrition education programs. In 1995, federal funding of those programs was at the $2.3M level; by l996, the funding level had risen to $36M, with equal matching for a $72M investment. The amount grows yearly and is now at $46M, with a match for a total of $92M. As you know, the intent of these funds is to educate food stamp recipients and food stamp-eligible persons to use their stamps and dollars wisely to obtain food to meet their nutritional requirements and keep that food safe for consumption.

In the years since the establishment of these programs, the need for public support of food and nutrition programs continues as an increasing number and proportion of the population continue to be at risk of undernourishment. In those years, the scientific community expanded its findings regarding the linkage between nutrition and the physical, mental, emotional and social well-being of people. Research established the link between adequate nutrition in the early years and adult productivity. Research is establishing the link between adequate nutrition and risks of disease and disability. And some research establishes the linkage between nutrition education and nutritional intake. In fact, the entire issue of the December 1995 Journal of Nutrition Education was devoted to the findings regarding the impact of nutrition education based on a USDA-commissioned 10-year review of research.

Current Conditions

By the late l980s, the U.S. was entering an era of reformation of public policy and the role of federal, state and local government. It was also facing a rapidly growing federal budget. Thus, by l995, with the election of the 104th Congress, the stage was set for attempts to (1) reduce the federal budget, (2) move decision-making to the states and localities (new federalism or devolution) and (3) expect people currently on "welfare" to accept personal responsibility and become self-sufficient by becoming employed.

At the same time, with the ending of the Cold War and the vestiges of the Great Depression, the public was reconsidering other policies that have existed for nearly 60 years. A relevant piece of legislation was the passage of the l996 Farm Bill, known as the "Freedom to Farm Bill." Just as "welfare reform" is historic in that it changes welfare as we've known it, the Farm Bill of l996 begins to undo years of federal subsidies for farming. At the same time, it reauthorized the Food Stamp Program for two years, during which debate will continue about the linkage between nutrition programs and welfare reform and the goals we want for the economic, social and physical well-being of our children and the general population. All nutrition programs were part of the discussion on welfare reform in l995 and l996. The Society for Nutrition Education was particularly active in stating its position on the relationship between nutrition, nutrition education and the well-being of the nation in both specially created position papers and in articles in its journal.⁸

While most nutrition programs were left intact, or with some reduction in funds, the Food Stamp Program was most affected. Nearly half of the budget reduction related to welfare reform came from the Food Stamp Program. Those cuts most affect able-bodied adults, disabled children and adults, and immigrants-the latter being the most contentious for states like Minnesota with a large immigrant population. And if you heard the State of the Union address, the President and a few members of Congress want to revisit some aspects of the law in 1997. Our board will continue to monitor and influence the federal legislation. You'll want to do likewise, especially with your state and county response to the legislation. In l998, the Food Stamp Program will again be part of the national debate as it will be up again for continuation.

Clearly the intent of the l996 federal welfare reform legislation was to shift more of the financial burden and the decision-making responsibility for public assistance programs, specifically what was AFDC, now TANF, to the states and localities. The reasoning was that better policy and programs could be done by those closest to the people served. For that reasoning to hold, state and local decision makers need a comprehensive understanding of the situation facing children, families and communities as all families strive to fulfill their functions so that at least basic needs are met and hopefully, more than that.

A central premise of welfare reform is that individuals should earn a living to buy basic needs-that they should be personally responsible for their financial well-being and that of any children they bear. Not only are they to be responsible but self-sufficient, generally meaning (in this legislation) earning an income to purchase those basic needs and not using public assistance.

At issue are the ability to earn income, what level of income an individual must have to meet his or her needs and those of any dependents, and the availability and cost of basics to be purchased, such as food, housing, public transportation to jobs, etc. Any policies based on income generation must have access to research-based data for wise decision making.

Thus, in Minnesota, Drs. Jean Bauer and Kathy Rettig of our Family Social Sciences Department researched the costs of food and of other basic needs and published booklets through the University of Minnesota Extension Service which show the costs of living.^2,10 Dr. Bauer further analyzed costs for people living below poverty, at poverty and above. She compared these costs to the "income" received through public assistance and wages. Her analysis shows a gap for those on public assistance and at low wages which keeps those individuals at or below poverty. She especially addressed this gap in our January 23 satellite conference. This kind of data is needed by those setting welfare reform policy-which is based on the premise that people are employed and paying for their own needs rather than receiving assistance.

For those interested in the relationship between food and costs, there are data available to show the numbers of people who are hungry because there is a gap in the money they have available for food and in the food requirements for their age and stage in life. Wisconsin did a hunger study under the direction of Jane Vocheck. In Texas, under the leadership of Dr. Kathleen Ladwig, a similar study's findings will be released next week. Dr. Bauer's analysis shows that food costs account for a much higher percentage for these people at or below poverty than for people above poverty-30% compared to about 11%-thus reducing the amount of income that is available for their basics.

A second set of information, needed by decision makers to respond knowledgeably to welfare reform and to make wise state and local policy, is that of where food, and nutrition from that food, fits into well-being. Answers to that are found in the scholarly findings regarding the worth of nutrition programs.

Relevant Research Findings

The Center on Hunger, Poverty and Nutrition Policy at Tufts University School of Nutrition recently established a program, the Nutrition-Cognition Initiative, which is intended to broaden public awareness about the relationship between nutrition and cognition. In his introduction to a publication by the center, a professor of pediatrics cites the results of decades of research which has built a compelling case for the impact of nutrition on the development of children. As a result, Professor Pollitt states:

When the increase in poverty is combined with the likely detrimental effects of nutritional status and thus developmental status, the pediatrician predicts that the U.S. is headed for a crisis of enormous proportions.

Contained in the report are these new findings:

1) Undernutrition during any period of childhood can have negative results in the child's development and "is capable of producing progressive handicaps-impairments which remain throughout life.

Chronically undernourished children conserve energy for vital functions and thus limit their interaction with their world, which means they are less likely to develop appropriate social relationships or to explore their environment than their well-nourished peers.

Iron-deficiency anemia is the most prevalent nutritional disorder in the world and affects about a quarter of all low-income children in the US. It affects the child's ability to learn by reducing attention span and memory, producing a severe impact on cognitive development. At the same time, anemia puts children at greater risk of lead poisoning, which leads to neurodevelopmental disorders. Given that low-income children are more likely to live in an environment with greater risk of lead poisoning and that they are more likely to be anemic, they face a double whammy."¹⁷

The report emphasizes the economic costs to the individual and nation: those of opportunities lost-the loss of contributions that nutritionally deprived children might otherwise make to society as a whole and to the productivity and well-being of their families in their adult life.

The report goes on the state that a key predictor of adult productivity is the number of school years completed. Children impaired by nutritional deficiencies are more likely to drop out or benefit less from schooling. That condition often leads not only to diminished capacity to be self-sufficient and contributory members of society, but to the need for the provision of social services to make up for what they cannot provide for themselves.

Thus this research clearly establishes a link between nutrition and the ability to earn a living-the cornerstone of current welfare reform legislation. Unless children are adequately nourished, they cannot learn. If they cannot learn, they cannot earn. If they cannot earn, they cannot become personally responsible and self-sufficient.

As for working-age adults, four of the 10 leading causes of death in the US. are linked to diet, and diet plays a role in other health conditions which can reduce quality of life and productivity. As recently reported by USDA, "together seven diet-related health conditions cost society $250 billion each year in medical costs and lost productivity." The report goes on to say that "although the extent to which these costs might be reduced by an improved diet cannot be calculated precisely, some researchers estimate that proper diet might forestall at least 20 percent of the annual deaths from heart disease, cancer, stroke and diabetes." And finally they make the case than many of the risks for chronic diseases can be affected by behavior within a person's control.¹⁶ Research also provides evidence that "a disproportionate burden of diet-related disease is born by minority, low-income and educationally disadvantaged persons, [with] such populations having higher rates of high blood pressure, stroke, and diabetes mellitus than the general population...with most of these diseases occurring more frequently with advancing age."¹⁵

Thus, the research supports the conclusion that adults who are not adequately nourished are at risk of nutrition-related disease, which in turn reduces their ability to earn and increases the costs of health care. And older adults, who require the greatest amount of costly health care, could benefit mentally, emotionally and physically by adequate intake of safe and nourishing food. If adults are not able to pay for health care, the public pays. Thus health care access and affordability are in the public policy arena for the 105th Congress.

Clearly, nutrition is an unrecognized but vital component of any strategy for welfare reform that moves toward well-being and seeks system-based solutions. Nutrition's greatest connection is that of prevention or reduction of costly problems. Its payoff is not short-term; its payoff lies in the long term. Typically, however, public policy is short-term focused. Thus, policymakers need to understand the case for nutrition and nutrition education as a component of welfare reform and any economic development policy. Clear understanding of costs to benefits will be needed if nutrition and nutrition education are seen as a viable part of policy. The decision to fund such programs will need evidence of positive impact. Again, research-based information will be key.

Impact of federally funded nutrition programs

Undernutrition can be prevented and its effects modified. Research consistently shows that such programs as the federally funded School Breakfast Program and the Special Supplemental Food Program for Women, Infants and Children have positive effects on children's development. In fact, a USDA study found that every $1 spent on WIC yields $3 in savings in Medicaid. Another study by the GAO found that cost savings in averted medical and other related expenditures over the first 18 years of children's lives amounted to $3.50 for every $1 spent on WIC.⁹

In a study of the school breakfast program, children who participated were found to have significantly higher standardized achievement scores than eligible non-participants as well as significantly reduced absence and tardiness rates. Studies of school lunch programs found that the programs provided one-third to one-half of children's nutritional intake each day. And as the Tufts Center report states, improved nutritional intake and "conditions in the social environment can modify the developmental effects of biological and social risk factors to which the child is exposed in early life."

Based on these findings, many of the nation's business leaders are understanding that our country's well-being is in jeopardy unless we focus on children's welfare. In a statement by the Committee on Economic Development, an independent research and education organization of over 100 business executives and educators, they urged policymakers to "look beyond traditional classroom boundaries and provide early and sustained intervention in the lives of children." That intervention can occur in nutrition education programs targeted at children and their families, such as EFNEP.

Impact of Food Stamp Program

The Food Stamp Program, the nation's first line of defense against acute hunger, is intended to help low-income people buy food to improve their diets. Nearly 90% of the participants are children, the elderly or women, with children accounting for half of the participation. Some studies of those households receiving food stamps indicate that they attain a significantly larger proportion of recommended dietary allowances than do non-eligible participants, though many still fail to reach the established RDA standards on the average allotment of $.70 per person/day. Others concluded that participants increased at-home nutrient availability but evidence regarding nutrient intake is inconclusive. According to a government report, availability of food increases because food stamps increase total food expenditures, but there is no statistically significant evidence that food stamp recipients purchase more nutritious foods with one exception-calcium.⁹

The impact of a dollar's worth of food stamps is an increase of at-home food expenditure by an average of $.26 . That is, those households can substitute stamps for purchases of other items previously purchased by cash by $.74 per dollar.

The GAO estimates that about half of food stamp-eligible households are not participating in the FSP because they are unaware of their eligibility. A part of nutrition education could be to increase the awareness of eligibility and access to this entitlement program, thereby improving quantity of food available. With the increase in nutrition programs funded by Food Stamp Program money, those responsible need to consider the function and focus of nutrition education and to examine the findings from nutrition education to date.

Function and Focus of Nutrition Education

In December, l994, at a forum hosted by NASULGC's Board on Human Sciences, over 100 legislative staff, state and land-grant university specialists, representatives of professional societies, public interest groups, the food industry, the USDA and other government agencies, and staff from the White House attended a workshop to consider how parts of the food system interact. The interdisciplinary workshop provided an opportunity to make connections across food production, consumption, health and safety. Among the recommendations of the working groups was this: "Shifting nutrition education program goals to seek behavior change rather than mere nutrition literacy and enhancement of informed, responsible consumer participation in food safety."

A shift from information-only to behavior-change focus requires appropriate educational methodologies for appropriate targeted audiences. Specific suggestions for shifts in programming can be found in the literature from the Society for Nutrition Education.¹³ The art and science of education must be applied if the greatest return on the dollar is to be produced. Informational programs can reach large numbers of people. However, research shows that informational programs are limited in their ability to impact behavior. To produce conditions that lead to behavioral change is more costly in time-on-task, which is also the reason why change occurs. Some research estimates that 50 hours of appropriate learning experiences are required to produce change that is sustained over time. To document impact, some money must be allocated to data collection and analysis over time. However, when put into a short-range time frame, nutrition education could likely produce a cost-benefit ratio equal to that of WIC (3:1). Current estimates for the investment to savings ratio for CES programs is 3 or 4:1.¹

Currently, EFNEP has some historical data that reveals impact. As Wells Willis (National Program Leader, CSREES, USDA) reports, evaluation studies reveal that participants change their nutrient intake. Further, research findings show that families are able to save $20-30 per month at a one-time cost of $300 per family and that they increase their self-confidence-a key to breaking the cycle of dependence on assistance and a step toward personal responsibility and self-sufficiency.

The McKnight Foundation of Minnesota invested more than $13 million in its Families in Poverty Initiative, involving 34 projects in the Twin Cities between l988 and l993. The evaluation concurred with findings regarding program effectiveness reported by Lisbeth Schorr and others in recent years. Their findings went further to conclude that "modest first steps-arresting decline and developing a sense of direction and commitment to making progress-are important and valid outcomes." In Minnesota, EFNEP families reported that through the program they gained the ability to set food purchasing and consumption goals that led to better nutrition and to a sense of accomplishment. A number went on to tell that from those modest first steps, they were able to set and reach additional goals-including employment and what is called self-sufficiency-goals of welfare reform.¹¹

Empowerment as an outcome of nutrition education is the claim of a series of position statements prepared by Linda Benning at NASULGC for use by the ECOP Legislative Committee in dealing with issues related to welfare reform.¹ Those statements contribute to building the case that nutrition education is a strategy for empowering at-risk families because they can gain control over a significant portion of their lives. Thus, the opinions of educators and the testimonies of educational program participants support the conclusion that nutrition education can serve as a first step in moving toward personal responsibility and ultimately to self-sufficiency -keys to welfare reform.

Currently, the Family Nutrition Program of the Food Stamp Program is less able to produce evidence of impact. In part, that is because such data was not required as a condition for funding, partially because the focus until this current contract was on information dissemination and not on behavior change, and partially because the science of measuring impact is costly and hasn't been extensively applied to the programming. The estimated average cost of delivery is $300. If FNP begins to focus on behavior change which is substantiated over time, as is the case with EFNEP, then it will be in a better position to defend the use of taxpayers' dollars to educate people.

With the implementation of the Government Performance Results Act this next year, we will all be required to produce indicators of the impact of programs. We will be required to show that for every dollar going into nutrition education, people are learning and applying knowledge to their daily lives such that they are increasing their nutritional well-being so they can be or become productive, contributing citizens.

In addition to making a commitment to measuring behavior change directly related to nutrition education, we need to set and measures outcomes that link our nutrition education to outcomes of welfare reform. Thus, we may want to explore such assessment evaluation questions as suggested by Bruner and others who developed a framework for measuring effectiveness and efficiencies of exemplary service impacts. Bruner suggests that we need to know answers to questions about:

I am proposing, therefore, that if we will work with researchers to identify indicators of behavioral change and of impacts and defensible methods for collecting and measuring those indicators, that we can further build our case that nutrition education is a strategy for welfare reform-worthy of investment by both taxpayers and the private sector. Specific tactics are the subject of another session. Only you can determine those.

After examining the need for nutrition education in l994, a national committee crafted a strategic plan for nutrition, diet and health in which they build the case that the CES "is uniquely positioned to enhance society's capacity to address critical issues in nutrition, diet and health through education. Clearly, with its close tie to USDA and other nutrition research; its capacity for on-site and distance education through its network of faculty at all land-grant universities, faculty in every county and paraprofessionals in many; and its history of nutrition education and public issues education,¹⁴ CES is positioned to help decision-makers incorporate nutrition education into strategies for welfare reform. As early as l991, in a report on working with limited resource audiences, the committee of the land-grant universities and the USDA recognized the connection among basic life skills education-nutrition, parenting, financial management and job skills-and the prevention of long-term dependence on public assistance programs."¹²

Closing Comments: Case Made

So, to make the case, turn to the research which clearly establishes the link between nutrition and the ability to earn a living-the cornerstone of current welfare reform legislation. Unless children are adequately nourished, they cannot learn. If they cannot learn, they cannot earn. If they cannot earn, they cannot become personally responsible and self-sufficient.

What remains is for those of us in the Cooperative Extension System to articulate the case and to engage in exchanges that could lead to policy that focuses on the well-being of individuals, families, communities and the nation now and well into the next century. Do we have the will to find the way to make that happen? Only time will tell.

References

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