SNAP: How Do We Encourage Healthy Choices?

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As the rate of obesity climbs towards pandemic proportions, multiple studies have examined the correlation between food and income assistance programs and unhealthy food consumption in the United States. While obesity is a condition affecting populations of all income levels, it is well-known that obesity disproportionally affects those of lower socioeconomic status. Many members of this population also depend on the Supplemental Nutrition Assistance Program (SNAP), formally known as the Food Stamps Program, to meet their nutritional needs. Under current regulations, there are no restrictions regarding using SNAP benefits to purchase unhealthy foods such as soda, sugary baked goods, and other ‘junk food’ that could very well be contributing to rising obesity rates among those of lower strata. This lack of regulation has persisted despite the existence of other historically successful food benefit programs such as the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) that have very specific constraints regarding the use of benefits. This information makes the question of whether restrictions should be placed on SNAP in order to stem the flow of empty calories a relevant and poignant one.

A recent clinical trial by Harnack et al. examined the effect of incentivizing fruit and vegetable purchases while restricting less nutritious foods within a food benefit program revealed interesting results. Lower-income participants not already enrolled in SNAP were provided with debit cards provisioned with funds over a 12-week period of time and randomized to one of four groups: (1) incentivized (30% less cost for fruits and vegetables); (2) restricted from purchasing sugary beverages, baked goods or candies; (3) combination of incentive and restriction parameters; or (4) no incentives or restrictions. Participants were then asked to complete daily dietary recall entries in food journals that were analyzed for nutritional content as determined by energy intake, fruit and vegetable selections, and purchases of less healthy food choices.

Interestingly, what they found was that while the groups provided with either an incentivized or restricted food assistance program did result in slightly healthier food choices, when the two were combined, the effects were synergistic and more widespread, resulting in greater whole fruit intake, decreased consumption of calories from sugary beverages, baked goods or candy, and reduced overall intake of daily calories (96 calories less), particularly of the discretionary variety derived from sugars and saturated fats (64 of the 96 fewer calories). The researchers concluded that a food benefit program pairing incentives for consumption of healthy food choices with restrictions of less nutritious selections may improve an individual’s overall dietary pattern.

As with all research, this study presents data that should be analyzed while keeping certain limitations in mind. The fact that these individuals were aware that they were part of a study from the very beginning may in itself alter their subsequent actions as part of a phenomenon known as the Hawthorne effect. Participants who may not normally select healthy food items could be incentivized by the subsidy of fresh produce, but also could just as easily be motivated to make a favorable impression through more nutritional choices.

What would be the effect of switching participants between groups? For example, would a person who was originally offered the fruit and vegetable subsidy continue to purchase produce without the incentive? Would a participant who started with restrictions be more likely to purchase fruit and vegetables with this incentive during a subsequent trial period?

Despite its imperfections, this study does offer numerous implications for policy development in the realm of food subsidies. What this data suggests is that providing beneficiaries gentle guidance in their food selections may improve their overall diet and consequently, their health. However, this issue has become complicated over the past two to three decades as pressure to reduce federal spending steadily increases. As a result, suggestions for policy change regarding incentives or restrictions on food subsidies are lost amidst the uproar caused by supervisory committees debating reducing or even eliminating funding for these programs. Multiple states including California, Nebraska and Illinois have called for reform of SNAP benefits and have been denied by Congress in part due to deadlock among policy makers.

However, this issue runs deeper than making simple changes in policy. Right now, the tactic commonly used to address this issue is a needs-based approach, assuming that people who lack access to food do so in a passive capacity and require direct assistance. The old adage of ‘give a man a fish and feed him for a day’ is incredibly pertinent here. While providing monetary assistance is one very important aspect of the issue, unless we make beneficiaries active participants in addressing their health problems, we perpetuate the problem rather than stop it. We must provide education regarding making smart diet selections, cooking at home, and choosing economical food purchases, or else we are not doing our due diligence in helping individuals overcome food insecurity. This presents an opportunity for health care workers including medical students to address this issue by taking time to counsel during clinical visits. Equipping patients with knowledge regarding proper nutrition and the health consequences of a poor diet allow providers to help patients take control of their health at a fundamental level.

The bottom line: the struggle to overcome polarization in the debate regarding food subsidiary program funding and regulations is not a new one. However, as far as the literature is concerned, this is the first clinical trial conducted to examine the effects of incentivizing or placing restrictions on the food choices that low-income individuals and families have via a food subsidiary program modeled after SNAP. The debate of whether this information can actually be maneuvered into influencing policy change is not novel, but it may bring us a step closer towards gaining meaningful ground against the obesity epidemic that incommensurately affects those paradoxically less able to afford healthy food choices. Thus, further research regarding combining incentives and restrictions on food subsidies is warranted in the effort to convince policy makers that placing parameters on these programs rather than reducing or eliminating funding will make the most difference in addressing food insecurity and its effect on obesity.

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