Using the Food Stamp Program and Other Methods to Promote Healthy Diets for Low-Income Consumers

Overconsumption of excessively sugared foods and beverages increases the risk of obesity, and people living in poverty are more likely to consume these nutrient-poor foods.¹ This is one reason why low-income consumers suffer disproportionately from such health disparities as higher rates of hypertension, diabetes, cardiovascular disease, obesity, and dental disease.^2,3 Excess consumption of beverages sweetened with sugar or high-fructose corn syrup (sugar-sweetened beverages, or SSBs) promotes both tooth decay and increased body weight in children while providing few or no essential nutrients.^4,5 The average adolescent consumes about 357 calories in SSBs each day, 67% of which comes from carbonated soft drinks.⁶

School nurse Jill Burgin, right, helps Alyssa Brown check her blood glucose level in the infirmary at Stiles Point Elementary on James Island, SC. Photograph by Tyrone Walker. Printed with permission of AP Photo.

The challenge for health officials is to devise policies that would promote healthier diets. Schools have long been involved in working to improve the nutrition environment for children, but a bigger challenge is to bring these same messages and policy changes to all of those at risk. Low-income Americans consume more SSBs than do other consumers, and food-stamp users appear to purchase at least 40% more SSBs than do other consumers. For instance, at one major supermarket chain, food-stamp users bought 4.3% of carbonated soft drinks even though they only represented 1.8% of transactions (M. F. J., unpublished data, May 2010).^7,8 Likewise, food-stamp users consume less fruit, vegetables, and whole grains, which provide essential nutrients.⁸

The federal Food Stamp Program, now known as the Supplemental Nutrition Assistance Program (SNAP), is by far America's largest “nutrition” program. SNAP is expected to provide $69 billion in benefits to roughly 43 million people in 2011.^9,10 By definition, SNAP is intended to help “low-income people and families buy the food they need for good health.”¹¹

SNAP clients can use their Electronic Benefit Transfer (EBT) card to purchase anything in a grocery store except dietary supplements, alcoholic beverages, tobacco products, hot prepared foods, and nonfood items.¹² Some nutritionists ask: if tobacco and alcohol can be excluded because of their risks to health, why not junk foods?

A seemingly obvious way to improve the diets and health of low-income Americans would be for Congress to prohibit SNAP funds from being used for the purchase of SSBs and other nonessential, relatively nonnutritious foods. Advocates of that approach argue that taxpayer dollars should not be wasted subsidizing the purchase of those foods. Moreover, as agriculture-policy expert Robert Paarlberg advised Congress, “Removing the soda subsidy would help correct the impression that our nutrition programs are hostage to the interests of [the] beverage industry.”¹³ Consider that carbonated soft drinks accounted for 6.19% of the grocery bills of food-stamp users at one large supermarket chain, compared to 4.38% for the average shopper (M. F. J. unpublished data, May 2010); thus, if food-stamp expenditures in fiscal year 2011 are about $69 billion,⁹ then almost $4 billion will be spent on carbonated soft drinks. This sum could be considered a direct subsidy to the soft drink and supermarket industries.

But efforts to limit SNAP purchases to healthier foods would draw intense opposition. The affected manufacturers, fearing lost sales from some of their best customers, would flex their political muscle to prevent restrictions and would probably donate money to nonprofit organizations to try to neutralize their opposition or obtain their support (as the soft drink industry did to fight a federal excise tax on soft drinks). In addition, some antipoverty organizations maintain that limiting food choices is patronizing and discriminatory to poor consumers, but that argument probably would garner little sympathy among the general public. Some economists argue that a ban might have little effect on soda consumption because most SNAP beneficiaries could simply substitute their own money for SNAP dollars. Finally, grocery stores, especially small ones, would plead that it would be costly and complicated to separate SNAP-eligible foods from SNAP-ineligible foods (though they currently separate out vitamin pills and other ineligible products). Clearly, the road to restricting SNAP to healthy foods is filled with land mines that could be removed only with great difficulty.

A far less controversial way to encourage healthier diets would be to add a given amount, such as 30 cents, back to an EBT card for every SNAP dollar used to buy healthier foods. The US Department of Agriculture (USDA), which administers SNAP, estimates that for every 10% decrease in the price of fruits and vegetables, SNAP users would increase purchases of fruits and vegetables by 6% to 7%.¹⁴ Congress recently provided $100 million over five years to test ways to use SNAP benefits to increase purchases of produce, but it might be years by the time the tests are done and analyzed and consequent program changes proposed and implemented. Another point of attack would be to eliminate “food deserts” in inner-city and rural communities. Doing so would give low-income consumers greater accessibility to nutritious foods. The federal government is investing $400 million to bring supermarkets to underserved communities, to encourage small stores to provide more healthy options, and to increase the availability of farmers markets that accept SNAP benefits.^15,16

The nation's largest nutrition education effort, SNAP-Ed, which is funded through SNAP, could be better utilized to improve diets. SNAP-Ed provides almost $400 million a year in matching grants to states to encourage low-income consumers to choose healthier diets. Regrettably, however, the USDA bars states from using SNAP-Ed funds for social-marketing campaigns to discourage the consumption of unhealthy foods. The USDA prohibits “nutrition education messages which convey negative messages or disparage specific foods, beverages or commodities, or which are not consistent with the Dietary Guidelines for Americans and MyPyramid.”¹⁷ Accordingly, the USDA stopped the Maine Center for Disease Control and Prevention, the California Department of Public Health, the San Francisco Bay Area Nutrition and Physical Activity Collaborative, and the Wyoming Department of Health from using SNAP-Ed funds to discourage the consumption of soft drinks.¹⁸ Lifting those restrictions, so obviously geared to protect junk-food manufacturers, would free up substantial funding for effective campaigns to spur SNAP participants (and others) to consume greater amounts of healthier foods and smaller amounts of unhealthy foods. The USDA should change its restrictive policy and allow states the freedom to encourage consumers to choose a healthy diet on a limited budget.

Considering the entrenched political roadblocks to improving SNAP and SNAP-Ed, Congress should fund the Institute of Medicine to review the goals of the programs, identify their successes and limitations, and recommend changes that would encourage healthier diets. An Institute of Medicine report could give reform-minded legislators an authoritative basis for policy changes.

Thanks to the American Recovery and Reinvestment Act of 2009 and the recent landmark health reform legislation, hundreds of millions of dollars have been provided to fund local, state, and national prevention efforts annually.^19,20 Some of that money will be used to improve diets, both by increasing consumption of healthful foods and reducing consumption of SSB, sodium, and the like. The new funds go through the US Department of Health and Human Services, rather than the USDA, which should facilitate the development of hard-hitting social-marketing efforts.

A totally different approach to improving diets is taxation. At least 24 states and the City of Chicago levy special sales or excise taxes on soft drinks or snack foods. Those taxes, paid by all consumers, raise substantial income, although the rates are too small to affect consumption significantly.²¹ Higher tax rates have been proposed in New York State, Philadelphia, and nationally, but the measures were defeated due in large part to multimillion-dollar campaigns financed by the soda-industry. A federal tax of 12 cents per 12-ounce serving could raise upward of $15 billion a year²² and cut the consumption of SSBs by about 10%.²³ Polls indicate strong public support for soda taxes, provided that the revenue is invested in health programs.

The federally subsidized school breakfast and lunch programs are managed by the USDA and have core goals similar to SNAP's. These programs have long excluded SSBs because those drinks provide nothing but empty calories.²⁴ A number of school systems have banned the sale of SSBs outside of federally subsidized meals, such as in vending machines and school stores. Thanks to public pressure and the threat of a lawsuit, the soft-drink industry has voluntarily removed 95% of all nondiet soft drinks from public schools (but not sports drinks, which have about half the sugar and caloric content of regular carbonated drinks).²⁵ The Institute of Medicine has proposed eliminating SSBs from school campuses altogether,²⁴ and Congress is considering legislation that would give the USDA the authority to do just that.

Improved labeling offers another means of reducing consumption of SSBs by everyone, not just low-income consumers. However, except for the calorie disclosure and the cryptic “sugars 39g” item on Nutrition Facts labels, nothing on a can of soda pop suggests that its contents are a major cause of one of the biggest health problems in the United States: obesity. The US Food and Drug Administration (FDA) is examining options for front-of-package labeling of all foods that would highlight foods' contents of calories, saturated and trans fat, sodium, and added sugars, all major nutrition concerns. Possible labeling schemes include “better for you” icons on deserving foods; red, yellow, and green dots signifying high, medium, or low levels of problem nutrients; and numerical or graphic symbols that summarize a food's overall nutritional value.²⁶ Earlier this year, the Institute of Medicine commenced a parallel study on front-of-package labeling, and major soft-drink bottlers have begun declaring calorie contents prominently on front labels.

Labels warning of the dangers of tobacco products have raised consumer awareness and contributed to the decline in their use, in combination with other measures such as increased taxes. In 2005, the Center for Science in the Public Interest petitioned the FDA to require SSB packaging to display health messages pertaining to weight gain, dental caries, and the preferability of alternative beverages,²⁷ but the FDA has not yet responded. Warning notices could be an important part of a comprehensive approach to reduce SSB consumption.

Unhealthy diets—featuring overconsumption of calorie-laden soft drinks, salty snack foods, fatty meat and dairy products, and foods prepared with partially hydrogenated oils, and underconsumption of fruits, vegetables, and whole grains—are causing serious health problems, the most obvious being obesity and gross dental decay, especially among the poor. The public health community needs to weave together a broad, creative, well funded program for steering Americans, especially the most vulnerable ones, toward healthier diets. Everyone—rich and poor alike, and most of all our children—would benefit.