Abstract
The Supplemental Nutrition Assistance Program (SNAP) provides a vital buffer against hunger and poverty for 47.6 million Americans. Using 2013 California Dietary Practices Survey data, we assessed support for policies to strengthen the nutritional influence of SNAP. Among SNAP participants, support ranged from 74% to 93% for providing monetary incentives for fruits and vegetables, restricting purchases of sugary beverages, and providing more total benefits. Nonparticipants expressed similar levels of support. These approaches may alleviate the burden of diet-related disease in low-income populations.
The Supplemental Nutrition Assistance Program (SNAP) aims to alleviate food insecurity and improve the health of low-income children and families.1 With a budget of $80 billion, SNAP currently serves 47.6 million Americans, including more than 20 million children.1,2
Despite recent efforts to promote nutritious food options in SNAP,3,4 there are no established nutritional guidelines for SNAP-eligible foods.5 Obesity and diet-related disease disproportionately affect low-income individuals6–8; thus, public health advocates and researchers have urgently sought to identify policies that could bolster the nutritional influence of SNAP.9–12 So far, monetary incentives show promise: an evaluation of the US Department of Agriculture–funded Healthy Incentives Pilot showed that providing a $0.30 per SNAP dollar incentive for fruits and vegetables resulted in a 25% increase in their consumption levels.13
The objective of this study was to identify strategies that would be perceived as most acceptable to improving the nutritional intake of SNAP participants, using a statewide sample of California adults, including an oversample of SNAP participants.
METHODS
Data were taken from the 2013 California Dietary Practices Survey (CDPS), a random-digit-dial telephone survey of California households that was administered both in English and in Spanish. Survey respondents included 1505 California adults with listed and unlisted landline telephone numbers and current participants of CalFresh (the statewide name for SNAP).14 CDPS has been administered biennially by the California Department of Public Health since 1989 to evaluate progress toward meeting national dietary and health guidelines. Data were weighted to the 2010 US Census and the 2013 CalFresh population to obtain statewide representative estimates of the general population and CalFresh participants, respectively. The analytic population comprised 889 CalFresh participants and 598 nonparticipants. Respondents whose CalFresh status was unknown (n = 18) were excluded.
As assessed in previous studies, 4 questions were included in the 2013 CDPS to assess support for various policies to improve the nutritional impact of CalFresh.15 Variation in support for policies by sociodemographic and dietary characteristics were examined by the Rao-Scott χ2 test.
RESULTS
Among CalFresh participants, support for all proposed nutrition policies ranged from 74% to 93% (Table 1). Ninety percent of CalFresh participants supported providing additional money for fruits, vegetables, and other healthful foods. Seventy-four percent supported removing sugary drinks from the list of products purchased with CalFresh, including 73% of program participants who reported consuming sugary drinks once a month or more frequently. Another 78% supported the combination of sugary drink removal and incentivizing healthy purchases. Finally, 93% of CalFresh participants supported the provision of more program benefits “to guarantee enough to eat and good nutrition.”
TABLE 1—
Support for Policy Proposals to Improve the Nutritional Impact of CalFresh by Sociodemographic and Dietary Characteristics From CalFresh Participants (n = 889): California Dietary Practices Survey, 2013
| Providing Additional Money to CalFresh Participants That Can Only Be Used on Fruits, Vegetables, and Other Healthful Foods |
Removing Sugary Drinks From List of Products Purchased Using CalFresh |
Both Removing Sugary Drinks and Providing Additional Money to CalFresh Participants That Can Only Be Used on Healthful Foods |
Providing CalFresh Participants More Benefits to Guarantee Enough to Eat and Good Nutrition |
|||||
| No. (%) | Pa | No. (%) | Pa | No. (%) | Pa | No. (%) | Pa | |
| Overall | 715 (90.3) | 467 (73.8) | 605 (77.8) | 764 (93.4) | ||||
| Age, y | ||||||||
| 18–34 | 236 (91.4) | .68 | 148 (76.5) | .57 | 198 (78.8) | .75 | 232 (89.9) | < .001 |
| 35–50 | 222 (89.7) | 148 (71.5) | 190 (78.3) | 247 (96.7) | ||||
| 51–64 | 181 (89.3) | 118 (71.2) | 149 (73.8) | 202 (98.4) | ||||
| ≥ 65 | 76 (85.2) | 53 (66.6) | 68 (77.6) | 83 (95.6) | ||||
| Gender | ||||||||
| Men | 213 (88.8) | .39 | 132 (68.4) | .08 | 166 (72.8) | .04 | 225 (91.1) | .15 |
| Women | 502 (91.3) | 335 (77.4) | 439 (81.1) | 539 (95.0) | ||||
| Race/ethnicity | ||||||||
| Non-Hispanic White | 210 (85.2) | < .001 | 139 (68.8) | < .001 | 178 (74.3) | .02 | 223 (87.8) | .007 |
| Non-Hispanic Black | 140 (87.0) | 65 (53.7) | 109 (66.2) | 159 (91.4) | ||||
| Hispanic | 250 (90.7) | 205 (86.5) | 229 (83.4) | 264 (96.3) | ||||
| Other | 115 (98.4) | 58 (71.2) | 89 (81.7) | 118 (97.4) | ||||
| Education | ||||||||
| ≤ high school | 387 (88.7) | .01 | 274 (76.6) | .35 | 338 (78.3) | .82 | 412 (91.3) | .009 |
| Some college | 199 (89.5) | 119 (71.8) | 164 (75.8) | 219 (94.6) | ||||
| College graduate | 128 (96.9) | 73 (67.2) | 102 (79.2) | 132 (99.0) | ||||
| Household income, $ | ||||||||
| < 15 000 | 449 (89.7) | .74 | 283 (72.6) | .84 | 371 (76.6) | .32 | 482 (92.8) | .45 |
| 15 000–< 25 000 | 146 (91.2) | 102 (73.7) | 134 (81.1) | 160 (95.8) | ||||
| ≥ 25 000 | 90 (92.2) | 58 (77.1) | 79 (84.1) | 93 (95.5) | ||||
| Household composition | ||||||||
| No children < 18 y | 282 (93.2) | .06 | 171 (68.8) | .18 | 224 (71.7) | .04 | 307 (95.7) | .28 |
| Children < 18 y | 433 (89.0) | 296 (76.0) | 381 (80.6) | 457 (92.4) | ||||
| Fruit and vegetable intakeb | ||||||||
| < 5 servings/d | 433 (91.5) | .63 | 281 (76.7) | .3 | 361 (77.4) | .63 | 474 (96.6) | .008 |
| ≥ 5 servings/d | 208 (90.3) | 140 (71.1) | 183 (79.5) | 212 (90.3) | ||||
| Sugary beverage intakec | ||||||||
| Never | 180 (93.1) | .17 | 121 (76.8) | .49 | 163 (88.0) | < .001 | 193 (93.8) | .89 |
| ≥ once a month | 534 (89.6) | 345 (73.0) | 441 (75.1) | 570 (93.3) | ||||
Note. Percentages were weighted to represent the 2013 CalFresh population aged ≥ 18 years.
P values based on the Rao-Scott χ2 test of association between sociodemographic or dietary categories and support for policy proposals among CalFresh participants.
Self-reported servings of fruits and vegetables consumed the previous day.
Self-reported frequency of drinking sweetened soda or fruit drinks.
Among nonparticipants, similarly high levels of support for the proposed CalFresh nutrition policies were observed, ranging from 87% to 92% (Table 2). Nonparticipants were more likely to support removing sugary drinks (P < .001) and pairing it with additional money for healthful foods (P < .001). CalFresh participants were more likely to support providing more total benefits (P = .001; data not shown).
TABLE 2—
Support for Policy Proposals to Improve the Nutritional Impact of CalFresh by Sociodemographic Characteristics From CalFresh Nonparticipants (n = 598): California Dietary Practices Survey, 2013
| Providing Additional Money to CalFresh Participants That Can Only Be Used on Fruits, Vegetables, and Other Healthful Foods |
Removing Sugary Drinks From the List of Products Purchased Using CalFresh |
Both Removing Sugary Drinks and Providing Additional Money to CalFresh Participants That Can Only Be Used on Healthful Foods |
Providing CalFresh Participants More Benefits to Guarantee Enough to Eat and Good Nutrition |
|||||
| No. (%) | Pa | No. (%) | Pa | No. (%) | Pa | No. (%) | Pa | |
| Overall | 385 (91.6) | 339 (87.3) | 380 (88.0) | 355 (86.8) | ||||
| Age, y | ||||||||
| 18–34 | 25 (92.5) | .99 | 22 (90.2) | .38 | 24 (89.5) | .9 | 25 (93.3) | .25 |
| 35–50 | 79 (91.7) | 65 (81.3) | 76 (86.8) | 74 (85.9) | ||||
| 51–64 | 116 (91.0) | 99 (87.3) | 114 (86.1) | 106 (84.3) | ||||
| ≥ 65 | 165 (91.1) | 153 (92.4) | 166 (90.1) | 150 (80.6) | ||||
| Gender | ||||||||
| Men | 137 (92.3) | .16 | 118 (87.2) | .97 | 131 (86.5) | .43 | 122 (87.4) | .77 |
| Women | 248 (90.8) | 221 (87.4) | 249 (90.0) | 233 (86.1) | ||||
| Race/ethnicity | ||||||||
| Non-Hispanic White | 258 (87.4) | .07 | 246 (89.9) | .68 | 261 (88.6) | .59 | 234 (82.0) | .06 |
| Non-Hispanic Blackb | 15 (97.6) | 7 (75.4) | 15 (94.8) | 16 (96.3) | ||||
| Hispanic | 65 (95.9) | 50 (84.1) | 60 (90.5) | 64 (95.5) | ||||
| Other | 47 (94.9) | 36 (87.1) | 44 (83.2) | 41 (85.7) | ||||
| Education | ||||||||
| ≤ high school | 108 (93.2) | .56 | 86 (77.7) | .04 | 111 (90.6) | .34 | 103 (88.4) | .82 |
| Some college | 107 (93.3) | 91 (92.5) | 102 (90.8) | 94 (84.7) | ||||
| College graduate | 170 (89.4) | 162 (93.0) | 167 (84.2) | 158 (86.8) | ||||
| Household income, $ | ||||||||
| < 15 000 | 43 (89.2) | .003 | 36 (83.8) | .42 | 45 (69.0) | .06 | 43 (79.6) | .64 |
| 15 000–< 25 000 | 72 (99.4) | 49 (80.4) | 64 (93.5) | 62 (90.5) | ||||
| ≥25 000 | 230 (89.1) | 221 (88.8) | 230 (87.2) | 215 (86.4) | ||||
| Household composition | ||||||||
| No children < 18 y | 286 (90.0) | .33 | 254 (86.9) | .88 | 284 (86.7) | .54 | 265 (84.5) | .3 |
| Children < 18 y | 99 (93.5) | 85 (87.7) | 96 (89.5) | 90 (89.5) | ||||
| Fruit and vegetable intakec | ||||||||
| < 5 servings/d | 248 (91.6) | .76 | 220 (86.8) | .78 | 242 (86.3) | .36 | 222 (85.4) | .26 |
| ≥ 5 servings/d | 114 (92.8) | 100 (88.4) | 111 (90.7) | 110 (92.1) | ||||
| Sugary beverage intaked | ||||||||
| Never | 195 (90.3) | .53 | 176 (88.2) | .78 | 194 (89.3) | .63 | 175 (83.8) | .28 |
| ≥ once a month | 189 (92.5) | 162 (86.8) | 185 (87.1) | 179 (88.7) | ||||
Note. Percentages were weighted to represent the 2010 California population aged ≥ 18 years.
P values based on the Rao-Scott χ2 test of association between sociodemographic or dietary categories and support for policy proposals among CalFresh nonparticipants.
Estimates may be unstable because of small sample sizes for non-Hispanic Black respondents.
Self-reported servings of fruits and vegetables consumed the previous day.
Self-reported frequency of drinking sweetened soda or fruit drinks.
DISCUSSION
SNAP participants are an important stakeholder group in discussions on how best to improve the program’s nutritional impact. Despite some differences, CalFresh participants and other Californians showed broad support for all policies to strengthen the nutritional impact of the program, corroborating previous studies conducted among program experts and the general public. A 2011 survey of SNAP stakeholders found majority support for monetary incentives for fruits and vegetables and restricting soda or other foods of little nutritional value.11 A 2012 national poll showed that most respondents, including SNAP participants, supported all proposals evaluated in this article.15 Collectively, these studies demonstrated broad support from diverse stakeholder groups for policies designed to improve the nutritional impact of SNAP.
Public health advocates, researchers, and policymakers need to work together to find effective strategies that alleviate food insecurity and promote dietary quality among program participants.6–8 Potential SNAP policy changes should be rigorously tested in pilot programs to evaluate their effectiveness and to identify unintended consequences. Basu et al. conducted a related study on the cost-effectiveness and health effects of these policies, showing that the largest benefits in terms of diet and health resulted from restricting sugary drinks.12
The primary study limitation was the response rates (22% for CalFresh participants vs. 15% for nonparticipants), which may result in sampling error. However, these response rates compare favorably to other telephone surveys, and low response rates have not been shown to substantially bias most survey results.16,17 The proportion of respondents who supported the proposed policies in this study was similar to the proportion of SNAP participants and the general public surveyed in previous studies,15,18 providing further evidence to be considered when evaluating proposed policy changes across diverse populations.
The results of this study showed overwhelming support from Californians, including program participants, for policies to improve the quality of foods purchased and to increase the quantity of benefits provided. A combination of approaches is needed to align SNAP with public health priorities to promote the health of all Americans.
Acknowledgments
The California Dietary Practices Survey (CDPS) is coordinated by the California Department of Public Health’s Nutrition Education and Obesity Prevention Branch and administered by the Survey Research Group of the Public Health Institute with funding from the US Department of Agriculture SNAP. Analyses, findings, and conclusions described in this article were not necessarily endorsed by the CDPS group.
Human Participant Protection
Institutional review board approval was not needed because secondary data from the CDPS were used to conduct this study. The CDPS is approved by State of California Health and Human Services Agency Committee for the Protection of Human Subjects.
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