Disparities in Diet Quality: No SNAPPY Solutions

The National Health and Nutrition Examination Survey (NHANES) tracks the health and dietary habits of the US population using periodic surveys and examinations. Dietary intake of individuals, assessed by 24-hour dietary recall, allows for examination of temporal trends in dietary patterns and their relation to social factors associated with health, such as race, income, and educational attainment.¹ Using data from 8 NHANES cross-sectional surveys between the years of 1999 and 2014, Zhang et al² examined whether dietary patterns of adult recipients of the Supplemental Nutrition Assistance Program (SNAP) have changed over this 15-year period.

Unfortunately, they report a persistent poor diet score among SNAP recipients over the 15-year period, based on the American Heart Association’s 2020 Strategic Impact Goals for diet. There was little or no improvement in sodium intake and worsening disparities in intake of both healthy foods (nuts/seeds, whole grains, and fish) and unhealthy foods (processed foods and added sugars). Participants in SNAP reported eating an average of only 1.3 servings of fruits and vegetables per day. This is below the intake of the higher-income group (2.0 servings per day) and far below the 7 to 9 servings per day recommended by the Dietary Approaches to Stop Hypertension (DASH) diet,³ the dietary pattern recommended by the American Heart Association for optimal cardiovascular health. In contrast, those in the higher-income group showed overall higher dietary quality with the initial survey and significant improvements in diet score over the 15-year period. These results are consistent with prior reports of lower diet quality among low-income individuals⁴ and document its persistence.

The reasons for this trend are likely multifactorial, including lack of availability of fresh fruits and vegetables in low-income neighborhoods (food deserts), targeted marketing of unhealthy foods in poor communities, lack of education to inform food purchases, or the fact that foods with lower nutrient quality are less expensive and stretch the SNAP dollar farther than buying fresh foods. The authors and others suggest that modifications to the SNAP program might be a tool to promote healthier purchasing patterns given the evidence for continued poor-quality diets in recipients.⁵

Determining whether modifications to the program are possible requires an understanding of the history of SNAP (formerly called food stamps). In 2017, SNAP provided financial assistance for food purchasing to more than 42 million Americans with allowances of approximately $30 per week per person at a cost of 57% of the budget of the US Department of Agriculture (<1% of the federal budget). The 50-year history of the program is complex and dynamic, and changes to the program have been driven by altruism and human compassion as well as political and economic realities.⁶ It is hypothesized that improvements in food quality for SNAP recipients would ultimately save money by reducing the cardiovascular disease risk and health care costs of its recipients. Funds for SNAP are distributed by a debit card system to individuals for purchasing food at supermarkets, convenience stores, or farmers’ markets. While there are a few limits on purchases (alcohol, tobacco, and nonfood household items are ineligible), SNAP has no nutritional standards for purchases.

Periodically there are proposals to restrict SNAP purchases of various categories of food, such as junk food, sugar-sweetened beverages, or foods considered luxury items. However, Congress and the US Department of Agriculture have repeatedly rejected these proposals based on both the administrative burden that restrictions may add and the perception that control of purchases would violate the right to make personal choices. In 2018 the Trump administration launched a new proposal they believe would reduce taxpayer costs to run the program and improve the nutritional content of purchases for SNAP. The proposed Harvest Box program, in which recipients would receive a selection of healthy foods while lowering the dollar amount for individual purchases of foods,⁷ has been criticized as paternalistic toward an economically vulnerable population.

However, there are indications that an approach to modifying the program to promote healthy choices would be welcomed by recipients. In a cross-sectional survey study, Leung et al⁸ reported that SNAP recipients support policies that facilitate purchases of healthful foods and limit purchases of unhealthful foods, specifically sugary beverages. Some trials have demonstrated that changes may lead to health benefits. A randomized trial tested the effects of an incentive program designed to encourage purchases of fresh fruits and vegetables. This trial demonstrated that a pricing incentive of 2-for-1 dollars for the purchase of fruits and vegetables was effective at increasing fruit and vegetable purchasing by SNAP recipients in a low-income rural Maine community.⁹ Another short-term trial, which provided a $30 per week selection of high-potassium foods (fruits, vegetables, nuts, and beans), led to increased consumption of fruits and vegetables and urinary potassium excretion.¹⁰ Interventions that provide rewards or incentives or have educational value might be palatable to government officials and those who receive benefits. Changes to SNAP are needed because of the poor diet of most of its recipients, and the goal should be to provide assistance in making healthy, affordable choices. The ongoing NHANES surveillance is an opportunity to examine the association of modifications to the program with its recipients’ diet quality.

Zhang et al² document a high prevalence and persistence of poor diet quality among SNAP recipients. The link between poor diet quality and poor health is well established. However, this study highlights the need for approaches to improve diet quality of SNAP recipients while treading lightly on individuals’ right to choose what they eat.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Miller ER III et al. JAMA Network Open.

Corresponding Author: Edgar R. Miller III, PhD, MD, Johns Hopkins University, 2024 E Monument St, Ste 1-500L, Baltimore, MD 21205 (ermiller@jhmi.edu).

Conflict of Interest Disclosures: None reported.