The Supplemental Nutrition Assistance Program, soda, and USDA policy: who benefits?

SNAP Participation Moderates Fruit and Vegetable Intake Among Minority Families With Low Income

OBJECTIVE

To examine the moderation effect of Supplemental Nutrition Assistance Program (SNAP) participation on the baseline fruit and vegetable (FV) intake of Hispanic/Latino and African American children and parents participating in the Brighter Bites program.

DESIGN

Cross-sectional.

SETTING

Houston, Austin, and Dallas, TX; Washington, DC; and Southwest Florida.

PARTICIPANTS

Self-reported surveys (n = 6,037) of Hispanic/Latino and African American adult-child dyads enrolled in Brighter Bites in Fall 2018.

VARIABLES MEASURED

Dependent variable, child FV intake; Independent variable, parent FV intake, and FV shopping behavior; Effect Measure Modifier, SNAP participation.

ANALYSIS

Quantitatively used mixed effects linear regression models to test if the effect of parental baseline FV intake and shopping behavior on a child's baseline FV intake differed by SNAP participation. Analyses were performed using STATA with significance set at P < 0.05 and 95% confidence intervals (CIs).

RESULTS

For parents that consumed FV ≥ 2 times/d at baseline, there was a 0.1 times increase in child FV intake at baseline among those who participated in SNAP as compared with those who did not participate in SNAP (ß = 0.1; 95% CI, 0.1-0.2; P = 0.001), and for parents who shopped at convenience stores ≥ 2 times/wk for FV, there was 0.6 times increase in child FV intake at baseline for those who participated in SNAP as compared with those that did not participate in SNAP (ß = 0.6; 95% CI, 0.3-0.9; P < 0.001).

CONCLUSIONS AND IMPLICATIONS

Supplemental Nutrition Assistance Program participation moderated the associations between FV intake among African American and Hispanic/Latino parents and children and FV shopping at convenience stores and child FV intake. Findings indicate a need for future interventions to promote SNAP participation among those eligible and improve access to FV.

Perceptions of a food benefit programme that includes financial incentives for the purchase of fruits and vegetables and restrictions on the purchase of foods high in added sugar

OBJECTIVE

To report perspectives of participants in a food benefit programme that includes foods high in added sugar (FAS) restrictions and FAS restrictions paired with fruits and vegetables (F/V) incentives.

DESIGN

Randomised experimental trial in which participant perspectives were an exploratory study outcome.

SETTING

Participants were randomised into one of three Supplemental Nutrition Assistance Program (SNAP)-like food benefit programme groups: (1) restriction: not allowed to buy FAS with benefits; (2) restriction paired with incentive: not allowed to buy FAS with benefits and 30 % financial incentive on eligible F/V purchased using benefits; or (3) control: same food purchasing rules as SNAP. Participants were asked questions to assess programme satisfaction.

PARTICIPANTS

Adults in the Minneapolis-St. Paul, MN metropolitan area, eligible for but not currently participating in SNAP who completed baseline and follow-up study measures (n 254).

RESULTS

Among remaining households in each group, most found the programme helpful in buying nutritious foods (88·2 %-95·7 %) and were satisfied with the programme (89·1 %-93·0 %). Sensitivity analysis results indicate that reported helpfulness and satisfaction with the programme may in some instances be lower among the restriction and the restrictions paired with incentive groups in comparison to the control group.

CONCLUSIONS

A food benefit programme that includes restriction on purchase of FAS or restriction paired with a financial incentive for F/V purchases may be acceptable to most SNAP-eligible households with children.

Household Supplemental Nutrition Assistance Program Participation is Associated With Higher Fruit and Vegetable Consumption

OBJECTIVE

Examine whether differences were present by Supplemental Nutrition Assistance Program (SNAP) participation in dietary patterns, achievement of dietary recommendations, and food security for children (aged 7-18 years) receiving free/reduced-price school meals.

METHODS

Cross-sectional study. Caregiver-child dyads at a pediatric clinic completed validated surveys. Food security, dietary patterns, and achievement of dietary recommendations were compared between child SNAP participants/nonparticipants.

RESULTS

Among 205 caregivers, 128 (62.4%) reported SNAP participation. Percentages of child SNAP participants/nonparticipants meeting recommendations were largely nonsignificantly different and overwhelmingly low. Supplemental Nutrition Assistance Program participants reported higher mean daily servings of vegetables (P = 0.01) and fruits (P = 0.01) than nonparticipants. Caregiver-reported household food security was not significantly different between SNAP participants and nonparticipants (P = 0.44).

CONCLUSIONS AND IMPLICATIONS

In this study, child-reported fruit/vegetable intakes were significantly higher among SNAP participants than nonparticipants, suggesting child SNAP participants may experience small but noteworthy benefits related to fruit/vegetable consumption. Additional supports are needed to achieve dietary recommendations.

Strengthening the Public Health Impacts of the Supplemental Nutrition Assistance Program Through Policy

The US Department of Agriculture (USDA) Supplemental Nutrition Assistance Program (SNAP) is the cornerstone of the US nutrition safety net. Each month, SNAP provides assistance to 40 million low-income Americans-nearly half of them children. A number of changes could strengthen the public health impacts of SNAP. This review first presents a framework describing the mechanisms through which SNAP policy can influence public health, particularly by affecting the food security, the diet quality, and, subsequently, the health of SNAP participants. We then discusspolicy opportunities with the greatest potential to strengthen the public health impacts of SNAP, organized into three areas: (a) food production and distribution, (b) benefit allocation, and (c) eligibility and enrollment. For each section, we describe current policy and limitations of the status quo, suggest evidence-based opportunities for policy change to improve public health, and identify important areas for future research.

Nutritional quality of retail food purchases is not associated with participation in the Supplemental Nutrition Assistance Program for nutrition-oriented households

The Supplemental Nutrition Assistance Program (SNAP) provides millions of low-income Americans food benefits and other forms of nutrition assistance. Evidence indicates that SNAP reduces food insecurity. However, there is a concern that the food benefit may increase the demand for less healthy foods more than healthier foods, thereby reducing the overall nutritional quality of the participant's food basket. This paper aims to examine the association of SNAP participation with the nutritional quality of food-at-home purchases of low-income households and to investigate the potential heterogeneity among consumers with different levels of nutrition attitude. This analysis used food purchase data from the USDA National Household Food Acquisition and Purchase Survey (FoodAPS). Our study sample included 2,218 low-income households, of which 1,184 are SNAP participants, and 1,034 are income-eligible nonparticipants. Multivariate regressions were performed to explore the SNAP-nutritional quality association. A household's nutrition attitude was measured using its response to a question on whether the household searched for nutrition information online in the last 2 months. Households that affirmed they had an online nutrition search were treated as nutrition-oriented households (21.2% of the low-income sample), and households that did not were considered less nutrition-oriented households (78.8%). For robustness, we also created an alternative nutrition attitude measure based on reported use of the nutrition facts label. We found that among less nutrition-oriented households, SNAP participants had a statistically significant 0.097 points (p = 0.018) lower Guiding Stars rating than low-income nonparticipants. However, there was no significant SNAP-nutritional quality association among nutrition-oriented households. In conclusion, SNAP participation was associated with lower nutritional quality of food purchases among less nutrition-oriented households, but not among nutrition-oriented households. The results suggest that the intended nutritional benefits of restrictions on purchases of healthy foods may not reach the subgroup of nutrition-oriented SNAP participants.

Trends in cyclical food expenditures among low-income households receiving monthly nutrition assistance: results from a prospective study

OBJECTIVE

Supplemental Nutrition Assistance Program (SNAP) benefits are rapidly depleted after distribution. This phenomenon, known as the benefit cycle, is associated with poor nutrition and health outcomes. However, to date, no study has evaluated trends in food expenditures before and after households receive benefits using prospective data, and whether these trends vary by household characteristics.

DESIGN

Generalised estimating equations were used to model weekly household food expenditures during baseline (pre-benefit) and intervention months by vendor (restaurants and food retailers). Food retailer expenditures were further evaluated by food category (fruits and vegetables and foods high in added sugar). All expenditures were evaluated by household composition, demographics and economic means.

SETTING

Minneapolis-St. Paul, Minnesota, metropolitan area.

PARTICIPANTS

Low-income households (n 249) enrolled May 2013-August 2015.

RESULTS

Weekly food retailer expenditures did not vary during baseline (pre-benefit), but demonstrated a cyclical pattern after households received benefits across all household characteristics and for both food categories, particularly for fruits and vegetables. Households with greater economic resources spent more throughout the month compared with those with fewer resources. Households with lower food security status experienced more severe fluctuations in spending compared with more food secure households.

CONCLUSIONS

Cyclical food purchasing was observed broadly across different household characteristics and food categories, with notable differences by household economic means and food security status. Proposed SNAP policy changes designed to smooth food expenditures across the benefit month, such as increased frequency of benefit distribution, should include a focus on households with fewest resources.

Consumption of sugar-sweetened beverages and obesity in SNAP-eligible children and adolescents

BACKGROUND

Low-income individuals who are eligible for nutrition assistance have been shown to consume a larger portion of their daily calories from beverages with added sugar. We examined the association between Supplemental Nutrition Assistance Program (SNAP) participation and self-reported sugar sweetened beverage (SSB) consumption as well as the association between self-reported consumption of SSBs and overweight/obesity in low-income children.

DESIGN

Cross-sectional analysis of 1455 SNAP-eligible U.S. children, ages 2-17, who completed a questionnaire and physical examination during the 2009-2010 National Health and Nutrition Examination Survey (NHANES).

RESULTS

SNAP-eligible children who received SNAP in the last month were more likely to drink soda in the last month [76.0% (2.2)] than those who did not receive benefits [70.5% (2.8)]. These children were also more likely to drink fruit drinks [74.8% (1.6) vs. 69.3% (3.1)]. Among youth in households receiving SNAP benefits, soda consumption in the past month was associated with a greater risk of obesity, particularly Hispanic youth [OR=1.93 (1.07, 3.50), p=0.0314] aged 2-5 [OR=2.71 (1.29, 5.69), p=0.0114]. Additionally, among youth in households receiving SNAP benefits, male children who consumed sugar-sweetened fruit drinks in the past month were significantly more likely to be overweight [3.13 (1.12, 8.73), p=0.0315] as compared to male peers who did not consume any sugar sweetened fruit drinks.

CONCLUSION

Among youth, SNAP recipients drink more SSBs than their eligible non-recipient peers. Our results indicate that certain populations of children receiving SNAP benefits and consuming SSBs are more likely to be overweight or obese when compared to their peers who receive SNAP benefits but do not consume SSBs.

The Supplemental Nutrition Assistance Program and Child Weight Status: A Review

CONTEXT

The Supplemental Nutrition Assistance Program (SNAP) is a food assistance program that helps Americans afford a healthy diet. However, its influence on children's weight status is unclear. This review examined the evidence of the relationship between SNAP participation and child weight.

EVIDENCE ACQUISITION

The following databases were searched: PubMed, EconLit, Web of Science, and the U.S. Department of Agriculture Economic Research Service. The last search was performed in October 2018. This systematic review gives a narrative synthesis of included studies.

EVIDENCE SYNTHESIS

Twenty-three studies that examined the weight outcomes of children aged 2-18 years and SNAP participation were included. Eleven studies found no significant relationship between SNAP and child weight outcomes. Nine found that SNAP participation was associated with increased weight outcomes in certain subpopulations, and four found that SNAP was linked to a predicted decrease in weight outcomes in some subpopulations. However, many of these studies did not address a key methodologic challenge: self-selection. Of those that did, five found that SNAP participation was associated with an increased risk of being overweight and elevated weight in certain subpopulations.

CONCLUSIONS

SNAP participation may help boys maintain a healthy body weight but can be a contributing factor in being overweight or obese in girls who are long-term participants, or who are already overweight. Food security and participation in multiple food assistance programs may be important modifiers. These findings are relevant to policymakers who are considering reducing SNAP funding or restructuring the program. Further research that utilizes strong designs is needed.

Cardiovascular Disease Prevention by Diet Modification: JACC Health Promotion Series

Reduction in excess calories and improvement in dietary composition may prevent many primary and secondary cardiovascular events. Current guidelines recommend diets high in fruits, vegetables, whole grains, nuts, and legumes; moderate in low-fat dairy and seafood; and low in processed meats, sugar-sweetened beverages, refined grains, and sodium. Supplementation can be useful for some people but cannot replace a good diet. Factors that influence individuals to consume a low-quality diet are myriad and include lack of knowledge, lack of availability, high cost, time scarcity, social and cultural norms, marketing of poor-quality foods, and palatability. Governments should focus on cardiovascular disease as a global threat and enact policies that will reach all levels of society and create a food environment wherein healthy foods are accessible, affordable, and desirable. Health professionals should be proficient in basic nutritional knowledge to promote a sustainable pattern of healthful eating for cardiovascular disease prevention for both healthy individuals and those at higher risk.

A Default Option to Enhance Nutrition Within Financial Constraints: A Randomized, Controlled Proof-of-Principle Trial

OBJECTIVE

This study aimed to examine the feasibility and initial efficacy of a novel default option intervention targeting nutritional quality of online grocery purchases within the financial constraints of food insecurity.

METHODS

Female undergraduates (n = 59) without eating disorder symptoms or dietary restrictions selected foods online with a budget corresponding to maximum Supplemental Nutrition Assistance Program benefits. Before completing the task again, participants were randomly assigned to receive a $10 incentive for selecting nutritious groceries (n = 17), education about nutrition (n = 24), or a default online shopping cart containing a nutritionally balanced selection of groceries (n = 18) to which they could make changes. Nutritional quality was quantified by using the Thrifty Food Plan Calculator.

RESULTS

Compared with the education condition, participants in the default condition selected significantly more whole grains and fruits and foods lower in cholesterol, saturated fats, sodium, and overall calories. There were no statistically significant differences in nutritional outcomes between the incentive condition and the other two groups.

CONCLUSIONS

Findings provide initial support for the efficacy of a default option in facilitating healthier food choice behaviors within financial constraints.

Participant Satisfaction with a Food Benefit Program with Restrictions and Incentives

BACKGROUND

Policy makers are considering changes to the Supplemental Nutrition Assistance Program (SNAP). Proposed changes include financially incentivizing the purchase of healthier foods and prohibiting the use of funds for purchasing foods high in added sugars. SNAP participant perspectives may be useful in understanding the consequences of these proposed changes.

OBJECTIVE

To determine whether food restrictions and/or incentives are acceptable to food benefit program participants.

DESIGN

Data were collected as part of an experimental trial in which lower-income adults were randomly assigned to one of four financial food benefit conditions: (1) Incentive: 30% financial incentive on eligible fruits and vegetables purchased using food benefits; (2) Restriction: not allowed to buy sugar-sweetened beverages, sweet baked goods, or candies with food benefits; (3) Incentive plus Restriction; or (4) Control: no incentive/restriction. Participants completed closed- and open-ended questions about their perceptions on completion of the 12-week program.

PARTICIPANTS/SETTING

Adults eligible or nearly eligible for SNAP were recruited between 2013 and 2015 by means of events or flyers in the Minneapolis/St Paul, MN, metropolitan area. Of the 279 individuals who completed baseline measures, 265 completed follow-up measures and are included in these analyses.

STATISTICAL ANALYSIS

χ² analyses were conducted to assess differences in program satisfaction. Responses to open-ended questions were qualitatively analyzed using principles of content analysis.

RESULTS

There were no statistically significant or meaningful differences between experimental groups in satisfaction with the program elements evaluated in the study. Most participants in all conditions found the food program helpful in buying nutritious foods (94.1% to 98.5%) and in buying the kinds of foods they wanted (85.9% to 95.6%). Qualitative data suggested that most were supportive of restrictions, although a few were dissatisfied. Participants were uniformly supportive of incentives.

CONCLUSIONS

Findings suggest a food benefit program that includes incentives for purchasing fruits and vegetables and/or restrictions on the use of program funds for purchasing foods high in added sugars appears to be acceptable to most participants.

The Challenge in Improving the Diets of Supplemental Nutrition Assistance Program Recipients: A Historical Commentary

This paper provides a historical background for the current nutrition issues faced by the Supplemental Nutrition Assistance Program (SNAP). The Food Stamp Program evolved into SNAP during a period when U.S. diets, particularly those of the poor, became less healthful. During the 1960s, the U.S. (Kennedy-Johnson era) addressed malnutrition first with a pilot project focused on retail sales and cash food stamps, which showed that low-income consumers purchased relatively healthy foods for a fairly high-quality diet. Southern politicians in the House of Representatives wanted a program similar to an earlier subsidized commodity distribution program. The pilot provided the evidence northern urban politicians sought, and they held the farm bill hostage until southern rural interests agreed to an unfettered Food Stamp Program that allowed purchases directly from retailers. A final Food Stamp Program law was incorporated into the farm bill and passed. This program shifted in 1977 to a full cash benefit system later, first using food stamps to act as cash and later an Electronic Benefit Transfer program. The program was designed at a time of a very healthful diet of lower-SES Americans. As diets of lower-income Americans changed and the entire food system shifted, the program has not been adjusted in any manner. Today, 50%-66% of the calories in the American diet, particularly that of low-SES Americans, come from highly processed foods containing excessive refined carbohydrates, sodium, unhealthy saturated fats, and added sugar. The SNAP design has not responded to these shifts in diet and the powerful interests controlling our food system. This twist in the U.S. diet and food system presents a major dilemma to those attempting to form a healthy food program based on the results of an effective pilot project.

Moving Beyond the Debate Over Restricting Sugary Drinks in the Supplemental Nutrition Assistance Program

To address the dual problem of food insecurity and poor nutrition, the U.S. Department of Agriculture has recently revised the nutrition standards for nearly all of its federal food programs to align with the Dietary Guidelines for Americans. One notable exception is the Supplemental Nutrition Assistance Program (SNAP). Policy proposals to restrict SNAP benefits based on nutrition quality (e.g., excluding sugary drinks) have generated controversy and have polarized previous research and advocacy allies. This essay presents many of the issues that have emerged, which include challenges about the feasibility, justification, and effectiveness of restricting benefits; the risk of a slippery slope; concerns about participant dignity; and finally, distrust about the motives behind promoting and opposing a policy change. The purpose of this review is to increase mutual understanding and respect of different perspectives. The conclusion is that the rationales behind both support and opposition to updating the policies regulating SNAP benefits based on nutrition are fundamentally the same-the belief that a fair and just society cares for and protects vulnerable citizens, which in this case are low-income Americans who need assistance affording healthy food. Recommendations include activities to restore trust between the public health and anti-hunger communities, authentic engagement of SNAP participants in the conversation, and an optional SNAP program that includes both incentives and restrictions.

Effects of Subsidies and Prohibitions on Nutrition in a Food Benefit Program: A Randomized Clinical Trial

IMPORTANCE

Strategies to improve the nutritional status of those participating in the Supplemental Nutrition Assistance Program (SNAP) are of interest to policymakers.

OBJECTIVE

To evaluate whether the proposed policy of incentivizing the purchase of fruits and vegetables and prohibiting the purchase of less nutritious foods in a food benefit program improves the nutritional quality of participants' diets.

DESIGN, SETTING, AND PARTICIPANTS

Lower income participants (n = 279) not currently enrolled in SNAP were randomized to 1 of 4 experimental financial food benefit conditions: (1) incentive (30% financial incentive for fruits and vegetables purchased using food benefits); (2) restriction (not allowed to buy sugar sweetened beverages, sweet baked goods, or candies with food benefits); (3) incentive plus restriction (30% financial incentive on fruits and vegetables and restriction of purchase of sugar sweetened beverages, sweet baked goods, or candy with food benefits); or (4) control (no incentive or restrictions on foods purchased with food benefits). Participants in all conditions were given a study-specific debit card where funds were added every 4 weeks for a 12-week period. Outcome measures were collected at baseline and in the final 4 weeks of the experimental period.

MAIN OUTCOMES AND MEASURES

Primary outcomes (from 24-hour dietary recalls) included intake of energy, discretionary calories, and overall diet quality.

RESULTS

A number of favorable changes were observed in the incentive plus restriction condition that were significantly different from changes in the control condition. These included (1) reduced intake of energy (-96 kcal/d, standard error [SE], 59.9); (2) reduced intake of discretionary calories (-64 kcal/d, SE 26.3); (3) reduced intake of sugar sweetened beverages, sweet baked goods, and candies (-0.6 servings/d, SE 0.2); (4) increased intake of solid fruit (0.2 servings/d, SE 0.1); and (5) improved Healthy Eating Index score (4.1 points, SE 1.4). Fewer improvements were observed in the incentive only and restriction only arms.

CONCLUSIONS AND RELEVANCE

A food benefit program that pairs incentives for purchasing more fruits and vegetables with restrictions on the purchase of less nutritious foods may reduce energy intake and improve the nutritional quality of the diet of participants compared with a program that does not include incentives or restrictions.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02643576.

Imbalanced insulin action in chronic over nutrition: Clinical harm, molecular mechanisms, and a way forward

The growing worldwide prevalence of overnutrition and underexertion threatens the gains that we have made against atherosclerotic cardiovascular disease and other maladies. Chronic overnutrition causes the atherometabolic syndrome, which is a cluster of seemingly unrelated health problems characterized by increased abdominal girth and body-mass index, high fasting and postprandial concentrations of cholesterol- and triglyceride-rich apoB-lipoproteins (C-TRLs), low plasma HDL levels, impaired regulation of plasma glucose concentrations, hypertension, and a significant risk of developing overt type 2 diabetes mellitus (T2DM). In addition, individuals with this syndrome exhibit fatty liver, hypercoagulability, sympathetic overactivity, a gradually rising set-point for body adiposity, a substantially increased risk of atherosclerotic cardiovascular morbidity and mortality, and--crucially--hyperinsulinemia. Many lines of evidence indicate that each component of the atherometabolic syndrome arises, or is worsened by, pathway-selective insulin resistance and responsiveness (SEIRR). Individuals with SEIRR require compensatory hyperinsulinemia to control plasma glucose levels. The result is overdrive of those pathways that remain insulin-responsive, particularly ERK activation and hepatic de-novo lipogenesis (DNL), while carbohydrate regulation deteriorates. The effects are easily summarized: if hyperinsulinemia does something bad in a tissue or organ, that effect remains responsive in the atherometabolic syndrome and T2DM; and if hyperinsulinemia might do something good, that effect becomes resistant. It is a deadly imbalance in insulin action. From the standpoint of human health, it is the worst possible combination of effects. In this review, we discuss the origins of the atherometabolic syndrome in our historically unprecedented environment that only recently has become full of poorly satiating calories and incessant enticements to sit. Data are examined that indicate the magnitude of daily caloric imbalance that causes obesity. We also cover key aspects of healthy, balanced insulin action in liver, endothelium, brain, and elsewhere. Recent insights into the molecular basis and pathophysiologic harm from SEIRR in these organs are discussed. Importantly, a newly discovered oxide transport chain functions as the master regulator of the balance amongst different limbs of the insulin signaling cascade. This oxide transport chain--abbreviated 'NSAPP' after its five major proteins--fails to function properly during chronic overnutrition, resulting in this harmful pattern of SEIRR. We also review the origins of widespread, chronic overnutrition. Despite its apparent complexity, one factor stands out. A sophisticated junk food industry, aided by subsidies from willing governments, has devoted years of careful effort to promote overeating through the creation of a new class of food and drink that is low- or no-cost to the consumer, convenient, savory, calorically dense, yet weakly satiating. It is past time for the rest of us to overcome these foes of good health and solve this man-made epidemic.

Intraclass correlation and design effect in BMI, physical activity and diet: a cross-sectional study of 56 countries

OBJECTIVES

Measuring the intraclass correlation coefficient (ICC) and design effect (DE) may help to modify the public health interventions for body mass index (BMI), physical activity and diet according to geographic targeting of interventions in different countries. The purpose of this study was to quantify the level of clustering and DE in BMI, physical activity and diet in 56 low-income, middle-income and high-income countries.

DESIGN

Cross-sectional study design.

SETTING

Multicountry national survey data.

METHODS

The World Health Survey (WHS), 2003, data were used to examine clustering in BMI, physical activity in metabolic equivalent of task (MET) and diet in fruits and vegetables intake (FVI) from low-income, middle-income and high-income countries. Multistage sampling in the WHS used geographical clusters as primary sampling units (PSU). These PSUs were used as a clustering or grouping variable in this analysis. Multilevel intercept only regression models were used to calculate the ICC and DE for each country.

RESULTS

The median ICC (0.039) and median DE (1.82) for BMI were low; however, FVI had a higher median ICC (0.189) and median DE (4.16). For MET, the median ICC was 0.141 and median DE was 4.59. In some countries, however, the ICC and DE for BMI were large. For instance, South Africa had the highest ICC (0.39) and DE (11.9) for BMI, whereas Uruguay had the highest ICC (0.434) for MET and Ethiopia had the highest ICC (0.471) for FVI.

CONCLUSIONS

This study shows that across a wide range of countries, there was low area level clustering for BMI, whereas MET and FVI showed high area level clustering. These results suggested that the country level clustering effect should be considered in developing preventive approaches for BMI, as well as improving physical activity and healthy diets for each country.

Supplemental nutrition assistance program participation and sugar-sweetened beverage consumption, overall and by source

INTRODUCTION

This paper examined patterns in adults' sugar-sweetened beverage (SSB) consumption and caloric intake by Supplemental Nutrition Assistance Program (SNAP) participation status and by source of purchases in the United States (US).

METHOD

Cross-sectional analysis of consumption of SSBs by source of purchases using 24-hour dietary recall data obtained from the US National Health and Nutrition Examination Survey 2003-2010 (N=17,891). Bivariate analysis and multivariable regressions were used to examine the association between SNAP participation and SSB calories consumed overall and by source.

RESULTS

SSBs account for approximately 12% of total daily caloric intake (258 kcal) among SNAP participants, higher than that of SNAP-eligible nonparticipants (9% total daily intake, 205 kcal) and SNAP-ineligible nonparticipants (6% total daily intake, 153 kcal). Among income-eligible adults, participating in SNAP is associated with 28.9 additional SSB calories, of which most were obtained from a store. From 2003-04 to 2009-10, SSB prevalence and caloric intake were flat among SNAP participants while it declined among both SNAP-eligible and SNAP-ineligible nonparticipants; this pattern held for all sources of SSBs except for those purchased from fast-food restaurants, which were not statistically reduced among nonparticipants.

CONCLUSION

SNAP participants consumed more SSB calories compared to SNAP-eligible nonparticipants; and their SSB prevalence and caloric intake trend was flat over the 2003-04 to 2009-10 period. SNAP-Education interventions that focus on improving access to healthy food in poor neighborhoods may benefit SNAP participants.

Ending SNAP subsidies for sugar-sweetened beverages could reduce obesity and type 2 diabetes

To reduce obesity and type 2 diabetes rates, lawmakers have proposed modifying Supplemental Nutrition Assistance Program (SNAP) benefits to encourage healthier food choices. We examined the impact of two proposed policies: a ban on using SNAP dollars to buy sugar-sweetened beverages; and a subsidy in which for every SNAP dollar spent on fruit and vegetables, thirty cents is credited back to participants' SNAP benefit cards. We used nationally representative data and models describing obesity, type 2 diabetes, and determinants of food consumption among a sample of over 19,000 SNAP participants. We found that a ban on SNAP purchases of sugar-sweetened beverages would be expected to significantly reduce obesity prevalence and type 2 diabetes incidence, particularly among adults ages 18-65 and some racial and ethnic minorities. The subsidy policy would not be expected to have a significant effect on obesity and type 2 diabetes, given available data. Such a subsidy could, however, more than double the proportion of SNAP participants who meet federal vegetable and fruit consumption guidelines.

The Supplemental Nutrition Assistance Program: Analysis of Program Administration and Food Law Definitions

Under the current version of the Supplemental Nutrition Assistance Program (SNAP), participants can purchase virtually any food or beverage (collectively, food). Research indicates that SNAP recipients may have worse dietary quality than income-eligible nonparticipants. Policymakers have urged the U.S. Department of Agriculture (USDA) to pilot SNAP purchasing restrictions intended to support a healthier diet, and state legislators have proposed similar bills. The USDA rejected these invitations, stating that it would be administratively and logistically difficult to differentiate among products, amid other concerns. However, the USDA's Dietary Guidelines for Americans and the Supplemental Nutrition Program for Women, Infants, and Children (WIC) do just that. Further, state governments define and differentiate among foods and beverages for tax purposes. This paper reviews several factors intended to inform future policy decisions: the science indicating that SNAP recipients have poorer diet quality than income-eligible nonparticipants; the public's support for revising the SNAP program; federal, state, and city legislators' formal proposals to amend SNAP based on nutrition criteria and the USDA's public position in opposition to these proposals; state bills to amend eligible foods purchasable with SNAP benefits; state retail food tax laws; and the retail administration and program requirements for both WIC and SNAP. The paper finds that the government has a clear ability to align SNAP benefits with nutrition science and operationalize this into law.

Self-reported use of Supplemental Nutrition Assistance Program benefits to purchase soda in a public health center population: Los Angeles County, California, 2012

To better inform local program planning for the Supplemental Nutrition Assistance Program (SNAP), the Los Angeles County Department of Public Health used self-reported data from a public health center population to examine the prevalence of benefits used to purchase soda. We performed statistical analyses, including multivariable regression modeling, using data from a local health and nutrition examination survey. The survey response rate was 69% (n=1,503). More than one-third of survey participants reported receiving, or living in a household where someone receives, nutrition assistance benefits. When asked, 33% (n=170) reported using these benefits to purchase soda "sometimes" and 18% (n=91) reported "often" or "always," suggesting that the use of program benefits to purchase soda was not uncommon in this subpopulation. These findings have meaningful policy and planning implications, as they contribute to ongoing dialogue about strategies for optimizing nutrition among SNAP recipients.

Searching for Public Health Law's Sweet Spot: The Regulation of Sugar-Sweetened Beverages

David Studdert and colleagues explore how to balance public health, individual freedom, and good government when it comes to sugar-sweetened drinks.

The Supplemental Nutrition Assistance Program and dietary quality among US adults: findings from a nationally representative survey

OBJECTIVE

To examine the association of the Supplemental Nutrition Assistance Program (SNAP) and diet quality among low-income adults.

PATIENTS AND METHODS

We examined US nationally representative data from the National Health and Nutrition Examination Surveys 2003-2004, 2005-2006, 2007-2008, and 2009-2010. The data were analyzed from October 7, 2013, to March 1, 2014. The analytic sample consisted of 4211 low-income adults aged 20 to 64 years, of whom 1830 participate in SNAP. We adhered to the National Cancer Institute method in calculating the Healthy Eating Index 2010 and other dietary indicators, such as empty calorie intake. Bivariate and multivariable regression was used to compare SNAP participants and income-eligible nonparticipants among the full sample and subsamples of age, sex, race/ethnicity, and food insecurity.

RESULTS

Compared with low-income nonparticipants, adjusted analyses reveal that SNAP participants had lower dietary quality scores overall (42.58 vs 44.36, P≤.0001) and lower scores for fruits and vegetables, seafood and plant proteins (1.55 vs 1.77, P≤.0022), and empty calories (9.03 vs 9.90, P≤.0001), but they exhibited comparable scores on whole grain, refined grain, total dairy, total protein, fatty acid, and sodium intakes. The association between SNAP participation and lower dietary quality was statistically significant among women, Hispanics, young adults, and individuals who were food secure.

CONCLUSION

Our analyses suggest that SNAP participants have lower dietary quality than their income-eligible nonparticipant counterparts. Although SNAP has an important role in providing nutrition assistance to eligible low-income individuals, interventions are warranted to improve the dietary quality of participants.

Sugar, stress, and the Supplemental Nutrition Assistance Program: early childhood obesity risks among a clinic-based sample of low-income Hispanics

The nationwide epidemic of pediatric obesity is more prevalent among Hispanic children than white children. Recent literature suggests that obesity has early origins, leading scholars to call for interventions in pregnancy and infancy. However, there is little theoretical or empirical research to guide the development of early prevention programs for Hispanics. The present study seeks to identify risk factors for early childhood obesity among a low-income, predominately Hispanic sample. Data were gathered to inform the design of a primary care childhood obesity prevention program targeting pregnancy through age 12 months. Baseline data were gathered on 153 women attending the clinic for prenatal care or for their child's 2, 6 or 12 month well-check. All women completed surveys on diet, exercise, social support, food security, stress, infant feeding practices, health, and demographics. For women with children (n = 66), survey data were matched with medical records data on infant weight. Results reveal that 55 % of women in the sample had an infant profiling in the 85th percentile or higher, confirming the need for an early childhood obesity intervention. While mothers exhibited several potential risk factors for childhood obesity (e.g. fast food consumption), only maternal consumption of sweets and sugar-sweetened beverages, stress, and SNAP (food stamp receipt) were associated with infant overweight. Findings further reveal that stress and SNAP relate to child overweight, in part, through mothers' sugar-sweetened beverage consumption. Results suggest that obesity prevention efforts must address specific individual choices as well as the external environment that shapes these consumption patterns.

Few changes in food security and dietary intake from short-term participation in the Supplemental Nutrition Assistance Program among low-income Massachusetts adults

OBJECTIVE

To examine whether short-term participation in the Supplemental Nutrition Assistance Program (SNAP) affects food security and dietary quality among low-income adults recruited from a Massachusetts-wide emergency food hotline.

METHODS

A 3-month, longitudinal study was conducted among 107 adults recruited at the time of SNAP application assistance. Outcomes included household food security (10-item US Department of Agriculture Food Security Survey Module), dietary intake (eg, grains, fruit) and diet quality (modified Alternate Healthy Eating Index). Data were analyzed using paired t tests and multivariable linear regression.

RESULTS

Supplemental Nutrition Assistance Program participation was not associated with improved household food security over 3 months (P = .25). Compared with non-participants, SNAP participants increased refined grain intake by 1.1 serving/d (P = .02), from baseline to follow-up. No associations were observed with other foods, nutrients, or dietary quality.

CONCLUSION AND IMPLICATIONS

Policies that simultaneously improve household food security and dietary quality should be implemented to support the health of low-income Americans participating in this crucial program.

Public support for policies to improve the nutritional impact of the Supplemental Nutrition Assistance Program (SNAP)

OBJECTIVE

To determine public attitudes towards federal spending on nutrition assistance programmes and support for policies to improve the nutritional impact of the Supplemental Nutrition Assistance Program (SNAP).

DESIGN

Participants answered survey questions by telephone assessing support for SNAP spending and proposed programme policy changes.

SETTING USA SUBJECTS

Survey of 3024 adults selected by random digit dialling conducted in April 2012, including 418 SNAP participants.

RESULTS

A majority (77%; 95% CI 75, 79%) of all respondents supported maintaining or increasing SNAP benefits, with higher support among Democrats (88%; 95% CI 86, 90%) than Republicans (61%; 95% CI 58, 65%). The public supported policies to improve the nutritional impact of SNAP. Eighty-two per cent (95% CI 80, 84%) of respondents supported providing additional benefits to programme participants that can only be used on healthful foods. Sixty-nine per cent (95% CI 67, 71%) of respondents supported removing SNAP benefits for sugary drinks. A majority of SNAP participants (54%; 95% CI 48, 60%) supported removing SNAP benefits for sugary drinks. Of the 46% (95% CI 40, 52%) of SNAP participants who initially opposed removing sugary drinks, 45 % (95% CI 36, 54%) supported removing SNAP benefits for sugary drinks if the policy also included additional benefits to purchase healthful foods.

CONCLUSIONS

The US public broadly supports increasing or maintaining spending on SNAP. The majority of respondents, including SNAP participants, supported policies to improve the nutritional impact of SNAP by restricting the purchase of sugary drinks and incentivizing purchase of healthful foods with SNAP benefits.

American adults eligible for the Supplemental Nutritional Assistance Program consume more sugary beverages than ineligible adults

BACKGROUND

There is considerable debate about whether sugar-sweetened beverages (SSBs) should be allowable purchases with benefits from the Supplemental Nutrition Assistance Program (SNAP).

PURPOSE

To examine national patterns in adult consumption of SSBs by SNAP eligibility.

METHODS

Cross-sectional analysis of 24-hour dietary recall data obtained from the National Health and Nutrition Examination Survey 2003-2010 (N=17,198), analyzed in 2013.

RESULTS

In 2003-2010, 65% of adults receiving SNAP consumed SSBs, averaging 307 cal daily, and 74 g of sugar. Compared to adults ineligible for SNAP, adults receiving SNAP consumed a higher percentage of SSBs (65% vs. 59%, p<0.001), more calories from SSB per capita (210 kcal vs. 175 kcal, p=0.001), and more daily calories from SSBs among drinkers (307 kcal vs. 278 kcal, p=0.008). Overall, per capita consumption from SSBs was highest among adults receiving SNAP (210 kcal, 9% total daily intake), followed by adults eligible but not participating in SNAP (192 kcal, 8% total daily intake)--both of which had significantly higher SSB consumption than ineligible adults (175 kcal, 8% total daily intake) (p<0.05).

CONCLUSION

Adults eligible for SNAP benefits consume more SSBs than ineligible adults.

Associations of food stamp participation with dietary quality and obesity in children

OBJECTIVE

To determine if obesity and dietary quality in low-income children differed by participation in the Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp Program.

METHODS

The study population included 5193 children aged 4 to 19 with household incomes ≤130% of the federal poverty level from the 1999-2008 NHANES. Diet was measured by using 24-hour recalls.

RESULTS

Among low-income US children, 28% resided in households currently receiving SNAP benefits. After adjusting for sociodemographic differences, SNAP participation was not associated with a higher rate of childhood obesity (odds ratio = 1.11, 95% confidence interval [CI]: 0.71-1.74). Both SNAP participants and low-income nonparticipants were below national recommendations for whole grains, fruits, vegetables, fish, and potassium, while exceeding recommended limits for processed meat, sugar-sweetened beverages, saturated fat, and sodium. Zero percent of low-income children met at least 7 of 10 dietary recommendations. After multivariate adjustment, compared with nonparticipants, SNAP participants consumed 43% more sugar-sweetened beverages (95% CI: 8%-89%), 47% more high-fat dairy (95% CI: 7%, 101%), and 44% more processed meats (95% CI: 9%-91%), but 19% fewer nuts, seeds, and legumes (95% CI: -35% to 0%). In part due to these differences, intakes of calcium, iron, and folate were significantly higher among SNAP participants. Significant differences by SNAP participation were not evident in total energy, macronutrients, Healthy Eating Index 2005 scores, or Alternate Healthy Eating Index scores.

CONCLUSIONS

The diets of low-income children are far from meeting national dietary recommendations. Policy changes should be considered to restructure SNAP to improve children's health.

Evaluating equity critiques in food policy: the case of sugar-sweetened beverages

Many anti-obesity policies face a variety of ethical objections. We consider one kind of anti-obesity policy - modifications to food assistance programs meant to improve participants' diet - and one kind of criticism of these policies, that they are inequitable. We take as our example the recent, unsuccessful effort by New York State to exclude sweetened beverages from the items eligible for purchase in New York City with Supplemental Nutrition Support Program (SNAP) assistance (i.e., food stamps). We distinguish two equity-based ethical objections that were made to the sweetened beverage exclusion, and analyze these objections in terms of the theoretical notions of distributive equality and social equality. First, the sweetened beverage exclusion is unfair or violates distributive equality because it restricts the consumer choice of SNAP participants relative to non-participants. Second, it is disrespectful or violates social equality to prohibit SNAP participants from purchasing sweetened beverages with food stamps. We conclude that neither equity-based ethical objection is decisive, and that the proposed exclusion of sugar-sweetened beverages is not a violation of either distributive or social equality.

Global obesity: trends, risk factors and policy implications

The worldwide increase in obesity and related chronic diseases has largely been driven by global trade liberalization, economic growth and rapid urbanization. These factors continue to fuel dramatic changes in living environments, diets and lifestyles in ways that promote positive energy balance. Nutritional transitions in low-income and middle-income countries are typically characterized by increases in the consumption of animal fat and protein, refined grains, and added sugar. This change is coupled with reductions in physical activity owing to more mechanized and technologically driven lifestyles. Given the high costs of obesity and comorbidities in terms of health-care expenditure and quality of life, prevention strategies are paramount, particularly in low-income and middle-income countries that must manage coexisting infectious diseases and undernutrition in addition to the obesity epidemic. As countries become increasingly urbanized, undernutrition and obesity can exist side by side within the same country, community or household, which is a particular challenge for health systems with limited resources. Owing to the scope and complexity of the obesity epidemic, prevention strategies and policies across multiple levels are needed in order to have a measurable effect. Changes should include high-level global policies from the international community and coordinated efforts by governments, organizations, communities and individuals to positively influence behavioural change.

Grocery store beverage choices by participants in federal food assistance and nutrition programs

BACKGROUND

Sugar-sweetened beverages are a target for reduction in the 2010 Dietary Guidelines for Americans. Concerns have been raised about sugar-sweetened beverages purchased with Supplemental Nutrition Assistance Program (SNAP) benefits.

PURPOSE

This paper describes purchases of non-alcoholic refreshment beverages among participants in the U.S. Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and SNAP.

METHODS

Grocery store scanner data from a regional supermarket chain were used to assess refreshment beverage purchases of 39,172 households in January-June 2011. The sample consisted of families with a history of WIC participation in 2009-2011; about half also participated in SNAP. Beverage spending and volume purchased were compared for WIC sampled households either using SNAP benefits (SNAP) or not (WIC-only). Analyses were completed in 2012.

RESULTS

Refreshment beverages were a significant contributor to expenditure on groceries by SNAP and WIC households. Sugar-sweetened beverages accounted for 58% of refreshment beverage purchases made by SNAP households and 48% of purchases by WIC-only households. Soft drinks were purchased most by all households. Fruit-based beverages were mainly 100% juice for WIC-only households and sugary fruit drinks for SNAP households. SNAP benefits paid for 72% of the sugar-sweetened beverage purchases made by SNAP households. Nationwide, SNAP was estimated to pay at least $1.7 to $2.1 billion annually for sugar-sweetened beverages purchased in grocery stores.

CONCLUSIONS

Considerable amounts of sugar-sweetened beverages are purchased by households participating in WIC and SNAP. The SNAP program pays for most of the sugar-sweetened beverage purchases among SNAP households. The upcoming SNAP reauthorization could be a good time to reconsider the program priorities to align public funds with public health.