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

  • Barry M. Popkin
    Correspondence
    Address correspondence to: Barry M. Popkin, PhD, Carolina Population Center, University of North Carolina, 137 E. Franklin St., Chapel Hill NC 27516
    Affiliations
    Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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      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.

      Introduction

      This paper focuses on the history of the evolution of the Supplemental Nutrition Assistance Program (SNAP). SNAP began as the Food Stamp Program (FSP). Prior to FSP, in the 1930s, various food programs fed 20 million people and focused on surplus U.S. commodities; the early era of FSP in the 1960s began with the same commodity model. The modern FSP begins in the 1960s.
      • Landers P.S.
      The Food Stamp Program: history, nutrition education, and impact.
      Concerned about poverty, President John F. Kennedy and his secretary of agriculture, Orville Freeman (1961–1969), initiated a dialogue that led to the Food Stamp Act under President Lyndon B. Johnson and ultimately the current SNAP. For political reasons related to getting adequate support in the U.S. Congress, FSP was aligned with the farm bill. It is important to understand that at one time rural Southern and Midwestern legislators wanted FSP to focus only on selected “non-luxury” foods, whereas urban legislators supported an unrestricted program based on the results of a pilot FSP project.
      • Hadwiger D.F.
      • Browne W.P.
      The New Politics of Food.
      • Kerr N.A.
      Drafted into the war on poverty: USDA food and nutrition programs, 1961-1969.
      The push for healthier diets for SNAP participants reflects a legislator shift in the American diet, particularly that of the poor, over the past 40 years.
      This short history follows several strands laid out here. First is the link between commodity food distribution and the farm bill stemming from the Commodity Credit Corporation, created in 1932 and added to the farm bill in 1935. Second are the political environments in the House and Senate agriculture committees and the impact of the food industry special interests on the farm bill.
      • Hadwiger D.F.
      • Browne W.P.
      The New Politics of Food.
      • Kerr N.A.
      Drafted into the war on poverty: USDA food and nutrition programs, 1961-1969.
      Third, and most linked to concerns about the current diets of SNAP recipients, is the history of the debate over the food stamp bill in the 1960s. Fourth is the remarkable transformation of the American diet from the 1960s to the present, driven by a transformation in the U.S. food chain from production to processing, distribution, marketing, and ultimately demand and consumption. Fifth is the question of who controls the current U.S. and global food systems. A brief discussion of this last issue sets the stage for the other articles in this Special Issue and the desire of many in the public health community to restrict SNAP purchases of selected foods and beverages.

      Food Commodity Distribution

      During the Great Depression in the 1930s, the U.S. experienced farm surpluses, unemployment, and hunger. The U.S. Department of Agriculture (USDA) Foods program, initiated to shore up farm prices and help farmers during the depression,

      USDA Food and Nutrition Service. Food Distribution. www.fns.usda.gov/fdd/fdd-history-and-background#1933_-_The_Commodity_Credit_Corporation_%28CCC%29_Charter_Act. Published 2013. Accessed September 6, 2015.

      focused on the paradox of widespread hunger while crops were being plowed under and livestock destroyed. In 1933, the Commodity Credit Corporation Charter Act enabled free commodity distribution, and the project was subsequently incorporated into the Agriculture Act of 1935. The USDA used a proportion of U.S. import duties to purchase key surplus crops. “USDA originally defined eligible outlets for these USDA Foods, which included schools (for lunch programs), nonprofit summer camps for children, charitable institutions, and needy families,”

      USDA Food and Nutrition Service. Food Distribution. www.fns.usda.gov/fdd/fdd-history-and-background#1933_-_The_Commodity_Credit_Corporation_%28CCC%29_Charter_Act. Published 2013. Accessed September 6, 2015.

      anticipating the National School Lunch Program. The foods provided under this program are not addressed here, as they varied over time and were themselves the focus of legislative negotiations more relevant to school food but less so to the history of SNAP.
      President Kennedy was greatly affected by the hunger he saw in West Virginia in 1960. His first executive order directed the USDA to provide nutritious food to needy households and schools rather than dispose of surpluses. At this time, Kennedy also announced the food program pilot projects, whose goals were to test out options for creating a larger-scale program.
      Agricultural Marketing Service
      Food Stamp Program: An Initial Evaluation of the Pilot Projects.
      Freeman, a former governor of Minnesota, farmer, and aide to Hubert Humphrey, implemented the pilots, and ultimately President Johnson proposed the Food Stamp Act of 1964.

      The Agriculture Committees and the Food Industry

      The evolution of farm bills and agriculture policies in the U.S. has been remarkable. Southern legislators controlled both the House and Senate Committees on Agriculture. Several of them were particularly powerful and based their efforts on agricultural constituencies’ concerns in the 1960s. The U.S. has seen a dramatic evolution in the agricultural system, its players, and their concerns between the 1960s and the present time. Today, food and beverage producers and processers, food service industries, and agribusinesses have gained direct control over farm production, and thus have been major backers of SNAP. Here “control” refers to the way agribusinesses, food service processors, food service companies, and retailers now purchase directly from farmers and dictate many production-related practices for large-scale agriculture in the U.S. (discussed below and linked with Figure 1).
      • Anand S.S.
      • Hawkes C.
      • de Souza R.J.
      • et al.
      Food consumption and its impact on cardiovascular disease: importance of solutions focused on the globalized food system: a Report From the Workshop Convened by the World Heart Federation.
      This evolution continues with new players and issues, which are discussed at the end of this brief history.
      Figure thumbnail gr1
      Figure 1Stages of the global agricultural system’s development.
      SNAP, Supplemental Nutrition Assistance Program; WWII, World War II.

      The 1961 Food Stamp Program Began With a 1961–1964 Pilot Effort

      In 1961, the initial FSP, a complex direct commodity distribution program, selected eight economically depressed areas for a 5-month pilot project. The areas included 137,816 individuals. Whereas previously all food was provided through direct distribution only, with FSP, low-income households purchased cash coupons and received extra dollar value back as food coupons (e.g., they paid $2 for food stamps worth $10), which they could take to retail stores to obtain food. Evaluation and special studies followed the pilot projects. The initial eight sites comprised one major pilot that showed that retail sales increased by 8% in participating stores and that small stores were able to participate. It also showed that more than 80% of food sales were animal-source foods and produce.
      Agricultural Marketing Service
      Food Stamp Program: An Initial Evaluation of the Pilot Projects.
      One of the sites in Pennsylvania was the subject of important research by a team of agricultural economists, whose detailed evaluation
      • Madden J.P.
      • Yoder M.
      Program Evaluation: Food Stamps and Commodity Distribution in Rural Areas of Central Pennsylvania.
      became a significant element leading to the Food Stamp Act of 1964. This group’s earlier research plus its review of the short pilot provided support for urban and liberal legislators’ desire for an unfettered cash program. By contrast, Southern Democrats in a Democratically controlled Congress and other farm state officials wanted a program focused on quite limited commodities. The Southern Democrats in the House wanted to ban soft drinks, luxury foods, and luxury frozen foods, though the latter two categories were never sufficiently defined.
      • Kerr N.A.
      Drafted into the war on poverty: USDA food and nutrition programs, 1961-1969.
      This debate merged consideration of the FSP bill with that of the 1964 farm bill, which was what the FSP proponents in Congress desired, as this was the only option these urban and more-liberal politicians saw to get FSP legislation passed as the Food Stamp Act of 1964. Although the FSP and farm bills were not combined initially, Freeman was heavily involved in legislative negotiations. An arrangement was ultimately worked out in which FSP excluded only purchases of alcohol, and the farm bill moved forward. Congress first passed the Food Stamp Act of 1964
      • Kerr N.A.
      Drafted into the war on poverty: USDA food and nutrition programs, 1961-1969.
      • Madden J.P.
      • Yoder M.
      Program Evaluation: Food Stamps and Commodity Distribution in Rural Areas of Central Pennsylvania.
      Public Law 88-525
      U.S. Government. H.R. 10222.
      and then approved the Farm Bill of 1964. The initial FSP was based on purchases of actual food stamps, whereby consumers paid part of the stamps’ value and received additional value in the stamps.
      The next decade saw the initiation of the War on Poverty and enormous battles over FSP. Senate reviews of the program found that the rural southern states were not promoting FSP adequately and experienced very low participation rates by ignoring the truly needy.
      • Kerr N.A.
      Drafted into the war on poverty: USDA food and nutrition programs, 1961-1969.
      In addition, many poor families could not afford the $2 per month purchase requirement. Southern legislators focused on FSP abuse, and both the Federal government and several nongovernmental organizations conducted reviews of American poverty. For example, a presidential commission wrote the report “The People Left Behind,”
      President’s National Advisory Commission on Rural Poverty
      The People Left Behind. Office of the President, ed..
      a private group documented hunger in the South,

      Citizens’ Board of Inquiry Into Hunger. Malnutrition in the United States. HUNGER, USA; 1968:16–38.

      and the Columbia Broadcasting System aired the powerful documentary Hunger in America in 1968. Many legislators attempted to move child nutrition and FSP to other agencies. But Freeman and his supporters wanted the USDA to become consumer focused and felt these programs needed to remain with that agency.
      During this period (1964–1968), many reports on hunger in America were published, and the U.S. Senate Select Committee on Nutrition and Human Needs held hearings and created initiatives to keep these issues in the public arena. Interestingly, this same committee a decade later issued the first national dietary guidelines, designed by Mark Hegsted, which called for a reduction in consumption of red meat, sugar, and salt and an increase in fruits, vegetables, and whole grains. However, the USDA and the meat industry lobbies managed to change these guidelines.
      • Oppenheimer G.M.
      • Benrubi I.D.
      McGovern’s Senate Select Committee on Nutrition and Human Needs versus the meat industry on the diet-heart question (1976-1977).
      At the same time, the commodity distribution program continued. In 1960, that program distributed only five foods. But over the next decade, the number and variety of commodities provided increased, and the commodity distribution program served 331 counties that had no FSP.
      • Kerr N.A.
      Drafted into the war on poverty: USDA food and nutrition programs, 1961-1969.
      By 1967, the FSP monthly purchase requirement was reduced to $0.50 per person or a maximum of $3 per family. Freeman worked hard to get FSP into the 480 nonparticipating counties, and advocates throughout the country urged state governments to expand outreach and related programs to enlarge FSP coverage. This tumultuous battle continued for the next decade
      • Hadwiger D.F.
      • Browne W.P.
      The New Politics of Food.
      before the Richard Nixon administration proposed phasing out USDA food distribution programs. This was accomplished when the Agriculture and Consumer Protection Act of 1973 required that all food programs make their food purchases through retail grocery sales only.
      U.S. Congress.
      Agriculture and Consumer Protection Act of 1973. P.L. 93-86.

      Last Major Expansion: The Food and Agricultural Act of 1977

      By 1977, a major legislative effort led to simplification of FSP, to better focus it on the poor, and to remove the purchase requirement. This occurred during a period when the farm bill was the major driving force, and political parties as well as food companies and retailers were interested in expanding retail food sales. The Food and Agriculture Act of 1977 was the last expansion of FSP in terms of attempting to increase its coverage and accessibility. Robert Greenstein, the Food and Nutrition Service administrator, and a series of congressmen led this effort (Senators George McGovern, Jacob Javits, Bob Dole, and Humphrey and Congressmen Mark Foley and Frederick Richmond).
      • Landers P.S.
      The Food Stamp Program: history, nutrition education, and impact.
      • Spitze R.
      The Food and Agriculture Act of 1977: issues and decisions.

      Diets in the 1960s and 1970s

      Before the 1970s, only one nationally representative dietary survey of individual food intake had been conducted, the USDA’s 1965–1966 National Food Consumption Survey. It collected 24-hour recall data on a nationally representative sample in one quarter (spring) of the year. Smaller previous surveys had collected household food consumption data in the 1930s and 1940s, but these data sets were never made available to researchers. The University of North Carolina Food Research Group has access to the 1965–1966 data, which are no longer available through the USDA. This group linked the 1965–1966 food composition table (FCT) to subsequent FCTs to examine nutrients and food components that were poorly measured or not measured in the 1965–1966 table (e.g., fiber was not measured for most foods in the first USDA FCTs) and to keep foods in the same food groups over time.
      • Popkin B.
      • Haines P.
      • Siega-Riz A.
      Dietary patterns and trends in the United States: the UNC-CH approach.
      The research group examined the differential trends in dietary intake in three nationally representative food consumption surveys—1965–1966 (n=13,934); 1977–1978 (n=29,803); and 1989–1991 (n=17,424)—using the same FCT and linked food groups. The group looked at shifts in the diets of low-SES whites and non-Hispanic blacks and contrasted them with those of high-SES whites and non-Hispanic blacks. High SES was defined as ≥12 years of education and income >350% of the poverty line and low SES as less than a high school education and income <185% of the poverty line. The sample included adults aged ≥19 years (N=32,406) and excluded pregnant and lactating women. To ensure comparability, the analysis used only the first day of dietary intake data and a food grouping system based on 56 nutrient-based food groups concentrating on fiber and fat.
      For this work, the University of North Carolina research group used its 1994 Diet Quality Index,
      • Patterson R.E.
      • Haines P.S.
      • Popkin B.M.
      Diet quality index: capturing a multidimensional behavior.
      which includes eight food and nutrient-based groups and is based on the extant U.S. dietary guidelines at that time, hence the greater focus on fat and cholesterol. The following list defines the components of the Diet Quality Index used in this study:
      • total fat <30%, saturated fat <10%
      • cholesterol <300 milligrams daily
      • five or more servings of vegetables and fruits
      • six or more servings of carbohydrates
      • protein <100% of the recommended daily allowance
      • sodium <2,400 milligrams
      • calcium >100% of the recommended daily allowance
      This index revealed a reversal of dietary patterns between the dietary intake in 1965 and the diets over time until 1989–1991.
      • Popkin B.M.
      • Siega-Riz A.M.
      • Haines P.S.
      A comparison of dietary trends among racial and socioeconomic groups in the United States.
      The broader trends for all groups followed general U.S. trends: reduced percentages of energy from fat and saturated fat, declining cholesterol, no change in fruit and vegetable servings, declining protein and sodium, and a widening calcium gap (based on calcium consumption below the Recommended Daily Allowance) showing a large calcium intake decline among low-SES blacks. In 1965, low-SES blacks consumed the most healthful diet according to those criteria, eating much less animal-source foods, more legumes, and less saturated fat, whereas high-SES whites consumed the least healthful diet. The study concluded that over time white and black low-SES groups reduced the quality of their diets, high-SES whites improved theirs, and high-SES blacks did not change theirs. But this was based on old criteria. The key results were as follows:
      • high-SES whites: remarkable shift in consumption of low-fat alternatives and increased intake of high-fiber foods, but subsequent re-analyses found a decline in nutrient-rich vegetables (e.g., spinach);
      • low-SES whites: increased consumption of low-fat foods but smaller reductions in high-fat foods and less positive fiber and vegetable shifts;
      • low-SES blacks: increased consumption of low-fat foods, reduced consumption of some high-fat foods, and noteworthy increases in high-fiber ready-to-eat cereals and fruits; and
      • high-SES blacks: increased fruit and vegetable intakes.
      Without going back to very old files, it is difficult to know if the conclusions published in 1999 in the New England Journal of Medicine (that the poor ate a diet of higher quality than the high-SES groups in 1965, with a reversal by 1989–1991) would hold with current dietary standards.
      • Popkin B.M.
      • Siega-Riz A.M.
      • Haines P.S.
      A comparison of dietary trends among racial and socioeconomic groups in the United States.
      Given that the saturated fat consumed in 1965 was likely to be either hydrogenated trans fat–laden margarine or Crisco type of hydrogenated solid fats, butter, or lard, the high-SES white diet in 1965 still would be considered less healthy than that of today. In addition, the declines in legume and protein consumption would be viewed as unhealthy trends, whereas any increase in fruits and vegetables for any higher-SES groups would be considered healthful.
      Another way to look at these results is that the proportion of U.S. adults with poor diets was high in 1989–1991, which even with new criteria, is still the case. Many studies have documented the poor quality of the 21st-century U.S. diet.
      • Reedy J.
      • Krebs-Smith S.M.
      Dietary sources of energy, solid fats, and added sugars among children and adolescents in the United States.
      • Krebs-Smith S.M.
      • Reedy J.
      • Bosire C.
      Healthfulness of the U.S. food supply: little improvement despite decades of dietary guidance.
      • Moeller S.M.
      • Reedy J.
      • Millen A.E.
      • et al.
      Dietary patterns: challenges and opportunities in dietary patterns research an Experimental Biology workshop, April 1, 2006.
      • Kant A.K.
      • Graubard B.I.
      Secular trends in patterns of self-reported food consumption of adult Americans: NHANES 1971-1975 to NHANES 1999-2002.
      • Kant A.K.
      Consumption of energy-dense, nutrient-poor foods by adult Americans: nutritional and health implications. The third National Health and Nutrition Examination Survey, 1988-1994.
      The intake of ready-to-eat or ready-to-heat highly processed food is excessive, as is defined elsewhere in detail
      • Poti J.M.
      • Mendez M.A.
      • Ng S.W.
      • Popkin B.M.
      Is the degree of food processing and convenience linked with the nutritional quality of foods purchased by U.S. households?.
      ; foods with added sugar and refined carbohydrates or saturated fat dominate U.S. diets; and intakes of legumes, fruits, and vegetables are well below recommended levels.
      • Poti J.M.
      • Mendez M.A.
      • Ng S.W.
      • Popkin B.M.
      Is the degree of food processing and convenience linked with the nutritional quality of foods purchased by U.S. households?.
      • Grimm K.A.
      • Blanck H.M.
      • Scanlon K.S.
      • Moore L.V.
      • Grummer-Strawn L.M.
      • Foltz J.L.
      State-specific trends in fruit and vegetable consumption among adults—United States, 2000-2009.
      • Slining M.
      • Popkin B.
      Trends in intakes and sources of solid fats and added sugars among U.S. children and adolescents: 1994–2010.
      • Slining M.M.
      • Mathias K.C.
      • Popkin B.M.
      Trends in food and beverage sources among U.S. children and adolescents: 1989-2010.
      The old dietary guidelines and subsequent extensive research on the quality of the U.S. diet, the consumption of added sugars, and food purchases reveal that this problem of a shift to a poorer-quality diet with large proportions coming from foods composed of refined carbohydrates, excessive added sugars and sodium, and unhealthy fats remains the case, even as the kilocalorie per capita of food purchases and intakes have declined.
      • Poti J.M.
      • Mendez M.A.
      • Ng S.W.
      • Popkin B.M.
      Is the degree of food processing and convenience linked with the nutritional quality of foods purchased by U.S. households?.
      • Slining M.
      • Popkin B.
      Trends in intakes and sources of solid fats and added sugars among U.S. children and adolescents: 1994–2010.
      • Ng S.W.
      • Slining M.M.
      • Popkin B.M.
      Turning point for U.S. diets? Recessionary effects or behavioral shifts in foods purchased and consumed.
      • Popkin B.M.
      • Hawkes C.
      The sweetening of the global diet, particularly beverages: patterns, trends and policy responses for diabetes prevention.
      The implications of this paper are that the rationale and motivation to create an FSP (now SNAP) design that did not place controls on the food purchased for low-income American household FSP recipients do not fit the modern food system and the purchasing and dietary intake of total SNAP-eligible households. Today, the SNAP-eligible participants eat a much poorer diet with excessive added sugar, high sodium, and high levels of unhealthy saturated fats.
      • Reedy J.
      • Krebs-Smith S.M.
      Dietary sources of energy, solid fats, and added sugars among children and adolescents in the United States.
      • Slining M.
      • Popkin B.
      Trends in intakes and sources of solid fats and added sugars among U.S. children and adolescents: 1994–2010.
      • Monsivais P.
      • Mclain J.
      • Drewnowski A.
      The rising disparity in the price of healthful foods: 2004–2008.

      Shifting U.S. and Global Agricultural Policies

      Researchers have found that the controllers of U.S. and global farm and food policies in the 21st century are very different from the controllers of the past. Today, a series of studies by agricultural economists have shown that not only in the U.S. but globally the major control over the U.S. food supply has shifted from the U.S. government to the food service chains, retail food outlets, packaged and processed food manufacturers, and agribusinesses, and they are the ones in the U.S. who profit most from the current farm bill.

      Muller M. Contributions of U.S. food and agricultural policy to the obesity epidemic: opportunities and recommendations. In: Agricultural Policy and Public Health. Wingspread, WI: Institute for Agriculture and Trade Policy; 2007.

      Figure 1 summarizes these shifts in the food and agriculture system and the controlling forces. Essentially, the U.S. has seen an amazing evolution in its agriculture system and the forces controlling it over the past century. For much of the 19th century, farmers had little support while the U.S. slowly developed the science and later the infrastructure for research to enhance farm productivity. This continued until World War II, but little government control or funding directly supported the farm sector. A remarkable transformation occurred after World War II, as literally in present value terms, billions of dollars were invested in rural electrification, rural credit, irrigation, and farmer subsidies, and the modern farm bills emerged.
      • Gardner B.L.
      American Agriculture in the Twentieth Century: How It Flourished and What It Cost.
      • Hunt D.B.
      • Schaffer Harwood D.
      • Ray Daryll E.
      U.S. agricultural commodity policy and its relationship to obesity.
      Some of it was indirect, such as in grain elevators and the national highway system. At that time, the U.S. government as well as European and other higher-income countries made major contributions to farmers and had a lot to say via shifts in relative prices based on an array of research and direct subsidies in what was grown and producer prices as well as crops grown. This changed not only in the U.S. but also globally over the past several 40 years.
      • Reardon T.
      • Chen K.Z.
      • Minten B.
      • et al.
      The quiet revolution in Asia’s rice value chains.
      A recent article
      • Anand S.S.
      • Hawkes C.
      • de Souza R.J.
      • et al.
      Food consumption and its impact on cardiovascular disease: importance of solutions focused on the globalized food system: a Report From the Workshop Convened by the World Heart Federation.
      summarizes the global changes in the food system.
      In the U.S., these large food companies lobby continuously for an unfettered SNAP that allows purchases of any food or beverage other than alcohol and for retention of the size of SNAP.
      • Hunt D.B.
      • Schaffer Harwood D.
      • Ray Daryll E.
      U.S. agricultural commodity policy and its relationship to obesity.
      • Schaffer H.D.
      • Hunt D.B.
      • Ray D.E.
      U.S. agricultural commodity policy and its relationship to obesity. Background paper developed for the Wingspread Conference on Childhood Obesity.
      Advocates of changes in SNAP to restrict unhealthy food and beverage purchases are conflicted by the need to retain the political support of the food and beverage manufacturers as well as agribusinesses and those focused on food insecurity and poverty (the public health community) as they fight to maintain SNAP’s number of enrollees and its dollar value for each recipient.
      At the same time, the U.S. is at a point where if the government either instituted a front-of-the-package logo
      to designate the healthfulness of the food or USDA used other research based on its dietary guidelines, government healthy food–related guidelines could be used readily to limit SNAP purchases to selected foods and beverages. All SNAP retailers can handle automated Electronic Benefit Transfer cards and supermarkets can readily automate such issues when they are computerized as they must be to handle Electronic Benefit Transfer transactions. It is quite feasible, then, to use the retailer controls to limit SNAP dollars to foods deemed appropriate in the most recent U.S. dietary guidelines or a new front-of-the-label U.S. Food and Drug Administration system, in contrast,
      U.S. DHHS, U.S. Department of Agriculture
      Scientific Report of the 2015 Dietary Guidelines Advisory Committee.
      to deny purchases of selected categories of the most unhealthy products. Several insurance companies have worked with retailers to design special loyalty-type cards to provide discounts for healthier foods, as examples in South Africa have shown.
      • Lambert E.V.
      • Kolbe-Alexander T.L.
      Innovative strategies targeting obesity and non-communicable diseases in South Africa: what can we learn from the private healthcare sector?.
      • Sturm R.
      • An R.
      • Segal D.
      • Patel D.
      A cash-back rebate program for healthy food purchases in South Africa: results from scanner data.

      Discussion

      A key issue in the current debate in the U.S. about the need to improve the quality of SNAP families’ diets is the lack of restrictions on purchases other than alcohol. The reasons for that decision were critical during the design, initiation, and expansion of SNAP. The current program has survived in spite of attempts at program reduction, cuts due to pressure from retailers, agribusinesses, and farm state congressional members as well as hunger and public health advocates. Clearly, many public health scholars want to improve SNAP participants’ diets. The USDA is open to considering research projects, but to date no state has offered a meaningful research design. A number of studies in this volume of the American Journal of Preventive Medicine address this topic in depth. This could entail eliminating purchases of selected foods, but this author notes that SNAP payments represent a limited proportion of food purchases for most households and that key substitutions between SNAP and non-SNAP food expenditures would possibly mitigate any such effort. Nielsen Homescan data, such as the data the University of North Carolina team has used, could examine shifts in purchase patterns following implementation of a prohibition on purchases of sugar-sweetened beverages (SSBs), for example, in some metropolitan areas in a state with many metropolitan areas.
      • Slining M.
      • Popkin B.
      Trends in intakes and sources of solid fats and added sugars among U.S. children and adolescents: 1994–2010.
      • Ng S.W.
      • Popkin B.M.
      Monitoring foods and nutrients sold and consumed in the United States: dynamics and challenges.
      This question is often posed: Are SNAP recipients more likely to be obese than SNAP-eligible people who are not SNAP participants? But this is the wrong question. The issue is, can the U.S. improve the diets and health of low-income SNAP recipients, the least healthy segment of the U.S. population, by restricting purchases with SNAP dollars to more health-promoting foods and beverages? This is very similar to the large debate that preceded the revisions of the National School Lunch Program and the Women, Infants, and Children program. The issue is not whether the program leads to obesity, but rather, given the current understanding of diet and health and the very poor diets of the poor SNAP-eligible population, whether SNAP can be used to improve the health of SNAP recipients. Yet, SNAP, the largest U.S. national food program and a major food safety net for the poor, has not tested models that might improve recipients’ diets. Recently, the American Beverage Association hired a lobbyist to fight any experimental program or change that might limit purchases of SSBs and other unhealthful foods. The food lobby, which has even supported school food and Women, Infants, and Children program improvements, is fighting such limits on purchases. What strange bedfellows health advocates have in Coca-Cola, Pepsi, and the food lobby.

      Cox S. Big Soda SNAP-ing up billions off government programs. www.salon.com/2013/05/20/big_soda_snap_ing_up_billions_off_government_programs_partner/. Published 2013. Accessed July 27, 2016.

      • Nestle M.
      • Baer N.
      Soda Politics: Taking on Big Soda (and Winning).
      The cruel irony, of course, is that health advocates need the food lobby to protect these programs but do not need the components that peddle unhealthful foods. These groups focus on selling commodities and packaged processed food. They historically have not focused on the health implications of SNAP for obesity, heart disease, and cancer rates among the poor or the positive impacts Women, Infants, and Children program revisions have had on recipients’ health (other papers in this Supplement Issue provide much more detail on this topic).
      • Landers P.S.
      The Food Stamp Program: history, nutrition education, and impact.
      • Rose D.
      Food stamps, the Thrifty Food Plan, and meal preparation: the importance of the time dimension for U.S. nutrition policy.
      • Popkin B.
      • Akin J.
      • Haines P.
      • Macdonald M.M.
      • Spicer D.S.
      Nutrition program options for maternal and child health.
      Institute for Agriculture and Trade Policy
      Food Without Thought: How U.S. Farm Policy Contributes to Obesity.
      This battle is repeated across the Americas. Global food organizations consider that all those concerned with obesity are trying to dictate the diets of the poor, remove free choice, and attack food companies trying to feed the population. In Chile and Mexico, research has linked obesity rates with food programs that do not adjust to the obesity epidemic and focus on inappropriate obesity-promoting foods and incentives.
      • Uauy R.
      • Kain J.
      The epidemiological transition: need to incorporate obesity prevention into nutrition programmes.
      • Fernald L.C.
      • Gertler P.J.
      • Hou X.
      Cash component of conditional cash transfer program is associated with higher body mass index and blood pressure in adults.
      These two countries adapted their programs to minimize their promotion of obesity. The U.S., on the contrary, has not done so and has published data to show it would matter.
      • Basu S.
      • Seligman H.K.
      • Gardner C.
      • Bhattacharya J.
      Ending SNAP subsidies for sugar-sweetened beverages could reduce obesity and type 2 diabetes.
      • Yen S.T.
      The effects of SNAP and WIC programs on nutrient intakes of children.
      One only has to look at the impacts of the fat tax (on selected foods high in saturated fat) in Denmark and the SSB tax in Mexico to know that incomes and prices do matter.
      • Jensen J.D.
      • Smed S.
      The Danish tax on saturated fat—short run effects on consumption, substitution patterns and consumer prices of fats.
      • Colchero M.A.
      • Popkin B.M.
      • Rivera J.A.
      • Ng S.W.
      Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study.
      • Smed S.
      • Scarborough P.
      • Rayner M.
      • Jensen J.D.
      The effects of the Danish saturated fat tax on food and nutrient intake and modelled health outcomes: an econometric and comparative risk assessment evaluation.
      These studies are among the tax studies in higher- and lower-income countries that show that consumers react strongly to price incentives. In other words, if SNAP benefits were shifted to ban some foods, it would essentially create price incentives for healthier food purchases.
      The SNAP situation
      • Brownell K.D.
      • Ludwig D.S.
      The supplemental nutrition assistance program, soda, and USDA policy: who benefits?.
      requires that the nation’s health professionals, First Lady Michelle Obama, President Barack Obama, and the food lobby cooperate to revise food programs to protect and not injure the health of the poor, as has been demonstrated in Chile and Mexico. Better diets can prevent such problems as diabetes among obese lower-income Americans. Paramount is a common ground whereby at a minimum the public health and food lobbies jointly support experiments that lead to improving the diets of the poor. The importance of the nation’s health requires that the U.S. follow the leads of countries like Chile and Mexico toward healthful programs.
      This paper is not meant to impugn the motives or behaviors of low-income Americans, as the foods they consume are dependent on forces that have made unhealthy foods the least expensive per kilocalorie
      • Monsivais P.
      • Perrigue M.M.
      • Adams S.L.
      • Drewnowski A.
      Measuring diet cost at the individual level: a comparison of three methods.
      • Drewnowski A.
      • Rehm C.D.
      Vegetable cost metrics show that potatoes and beans provide most nutrients per penny.
      • Drewnowski A.
      Obesity, diets, and social inequalities.
      • Maillot M.
      • Darmon N.
      • Darmon M.
      • Lafay L.
      • Drewnowski A.
      Nutrient-dense food groups have high energy costs: an econometric approach to nutrient profiling.
      • Drewnowski A.
      • Darmon N.
      Food choices and diet costs: an economic analysis.
      and have also led administrators to base SNAP on inadequate thrifty food plan costs.
      • Rose D.
      Food stamps, the Thrifty Food Plan, and meal preparation: the importance of the time dimension for U.S. nutrition policy.
      • Crockett E.G.
      • Clancy K.L.
      • Bowering J.
      Comparing the cost of a thrifty food plan market basket in three areas of New York State.
      • Davis G.
      • You W.
      Not enough money or not enough time to satisfy the Thrifty Food Plan? A cost difference approach for estimating a money-time threshold.
      Subsequent papers in this Supplement Issue lay out the pros and cons of creating SNAP food or beverage restrictions to improve the diets of SNAP recipients. One argument heard often is that income-constrained lower-income Americans are forced to purchase low-nutrient food and that these foods and beverages are much less expensive sources of calories.
      • Maillot M.
      • Darmon N.
      • Darmon M.
      • Lafay L.
      • Drewnowski A.
      Nutrient-dense food groups have high energy costs: an econometric approach to nutrient profiling.
      • Drewnowski A.
      New metrics of affordable nutrition: which vegetables provide most nutrients for least cost?.
      • Aaron G.J.
      • Keim N.L.
      • Drewnowski A.
      • Townsend M.S.
      Estimating dietary costs of low-income women in California: a comparison of 2 approaches.
      • Drewnowski A.
      Obesity, diets, and social inequalities.
      There are many other issues related to the ways large food companies, retailers, and agribusinesses have shaped SNAP and the country’s entire food system.
      • Anand S.S.
      • Hawkes C.
      • de Souza R.J.
      • et al.
      Food consumption and its impact on cardiovascular disease: importance of solutions focused on the globalized food system: a Report From the Workshop Convened by the World Heart Federation.
      U.S. food price dynamics over time have been formed by longer-term farm policy and corporate interests. At the same time, nutrition experts were responsible for the design of a food system that focuses first on reduced costs for corn, wheat, and soybeans and then on animal-source foods.
      • Popkin B.M.
      Agricultural policies, food and public health.

      Conclusions

      Only a randomized trial that tests random restrictions on SNAP participants in one or multiple regions or uses a difference-on-difference longitudinal model or a statistical design with the rest of the state and the country as controls will demonstrate the effectiveness of changes. As other research has shown and as is shown in this issue,
      • Slining M.
      • Popkin B.
      Trends in intakes and sources of solid fats and added sugars among U.S. children and adolescents: 1994–2010.

      Poti JM, Smith Tallie L. Improving dietary intake in the Supplemental Nutrition Assistance Program: more home-cooking or less fast food? Am J Prev Med. In press.

      SNAP participants and all low-income Americans consume large amounts of SSBs (M Mendez, University of North Carolina, unpublished observations). But they also consume other refined carbohydrates and nonessential junk food.
      • Reedy J.
      • Krebs-Smith S.M.
      Dietary sources of energy, solid fats, and added sugars among children and adolescents in the United States.
      Ideally, the Food and Drug Administration will institute in the next 2 years a front-of-the-package food profiling system.
      Such systems are used globally to either identify foods considered healthful (e.g., whole grains and reduced added sugar, sodium, and saturated fats) or unhealthful (with excessive added sugar, sodium, or saturated fats).
      • Rayner M.
      • Scarborough P.
      • Kaur A.
      Nutrient profiling and the regulation of marketing to children. Possibilities and pitfalls.
      • Roodenburg A.
      • Popkin B.
      • Seidell J.
      Development of international criteria for a front of package nutrient profiling system: International Choices Programme.
      • Corvalán C.
      • Reyes M.
      • Garmendia M.L.
      • Uauy R.
      Structural responses to the obesity and non-communicable diseases epidemic: the Chilean Law of Food Labeling and Advertising.
      Permitting only foods identified as healthy by this profiling system would be a systematic science-based way to apply current knowledge on diet and health to restrict SNAP purchases to healthier food. This idea could readily be tested in one metropolitan area with shifts in Electronic Benefit Transfer eligibility for selected foods and beverages, which is critical to understand whether a restriction on SSBs or any other unhealthful food or beverage would represent a useful step forward in promotion of public health among SNAP recipients.

      Acknowledgments

      Publication of this article was supported by the Physicians Committee for Responsible Medicine. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Physicians Committee for Responsible Medicine.
      I thank the Robert Wood Johnson Foundation (grants 67506, 68793, 70017, 71837) and NIH (R01DK098072, DK56350, and CPC P2C HD050924) for financial support. I also wish to thank Ms. Frances L. Dancy for administrative assistance and Ms. Lori Delaney for searching for obscure legal and other historical documentation.
      No financial disclosures were reported by the author of this paper.

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