Unemployment,SNAP Enrollment,and Food Insecurity Before and After California's COVID-19 Shutdown

ObjectivesTo examine whether the decrease in very low food security (VLFS) observed in California shortly after California's coronavirus disease (COVID-19) shutdown remained throughout Federal Fiscal Year (FFY) 2020. To investigate associations among unemployment, Supplemental Nutrition Assistance Program (SNAP) enrollment, and VLFS across FFY 2020.MethodsTelephone interview responses from mothers from randomly sampled households from low-income areas throughout California to the 6-item US Department of Agriculture Food Security Survey Module identified VLFS families. Logistic regression examined VLFS rates before vs after California's COVID-19 shutdown, with race/ethnicity, age, and education as covariates. Pearson correlations were calculated for unemployment, SNAP enrollment, and VLFS.ResultsMost (66.4%) of the 2,682 mothers were Latina. VLFS declined from 19.3% before to 14.5% after California's COVID-19 shutdown (adjusted odds ratio, 0.705; P = 0.002). The correlation for unemployment and SNAP household participation was 0.854 (P = 0.007), and for SNAP participation and VLFS was −0.869 (P = 0.005).Conclusions and ImplicationsPublicly-funded assistance programs may lower food insecurity, even during a time of increased economic hardship. Examining the specific factors responsible for the observed decline in VLFS has merit. Whether VLFS remains below the rate observed before California's COVID-19 shutdown is worthy of ongoing study.     

State Implementation of SNAP Waivers and Flexibilities During the COVID-19 Pandemic: Perspectives From State Agency Leaders

ObjectiveTo describe state agencies’ implementation of the Supplemental Nutrition Assistance Program (SNAP) during the first year of the coronavirus disease of 2019 (COVID-19) pandemic, barriers and facilitators to SNAP implementation, and recommendations to improve SNAP implementation.DesignQualitative methodology guided by Bullock's determinants of policy implementation framework using 7 semistructured, virtual focus groups in April 2021.SettingTwenty-six states representing all 7 US Department of Agriculture Food and Nutrition Service regions.ParticipantsFour focus groups with state-level SNAP administrators and 3 focus groups with state-level SNAP supportive services (Supplemental Nutrition Assistance Program-Education, Employment & Training, and Outreach) supervisors (n = 62).Phenomenon of InterestSupplemental Nutrition Assistance Program implementation during the COVID-19 pandemic.AnalysisThematic analysis using a phronetic iterative approach.ResultsSix primary themes emerged: the policy response, technology needs, collaboration, participant communication, funding realities, and equity. Implementation challenges included the design of waivers in the early pandemic response, inadequate federal guidance and funding, outdated technology, and prepandemic regulations limiting state authority. Modernized technology systems, availability of virtual programming, partnerships, and enhanced benefits facilitated SNAP implementation.Conclusions and ImplicationsSupplemental Nutrition Assistance Program administrators adapted their programs to deliver services virtually during the COVID-19 pandemic. These experiences highlighted the importance of certain policy determinants, such as modernized technology and streamlined application processes, to improve outcomes for SNAP participants and staff.     

Federal Food Program Participation and Beverage Intake Among Families With Low Household Income

ObjectiveExamine beverage intake among families with low income by household participation in federal food assistance programs.DesignCross-sectional study conducted in fall/winter 2020 via an online survey.ParticipantsMothers of young children insured by Medicaid at the time of the child's birth (N = 493).Variables MeasuredMothers reported household federal food assistance program participation, later categorized as Supplementation Nutrition Program for Women, Infants, and Children (WIC) only, Supplemental Nutrition Assistance Program-Education (SNAP) only, both WIC and SNAP, and neither. Mothers reported beverage intake for themselves and their children aged 1–4 years.AnalysisNegative binomial and ordinal logistic regression.ResultsAfter accounting for sociodemographic differences between groups, mothers from households participating in WIC and SNAP consumed sugar-sweetened beverages (incidence rate ratio, 1.63; 95% confidence interval [CI], 1.14–2.30; P = 0.007) and bottled water (odds ratio, 1.76; 95% CI, 1.05–2.96; P = 0.03) more frequently than mothers from households in neither program. Children from households participating in WIC and SNAP also consumed soda (incidence rate ratio, 6.07; 95% CI, 1.80–20.45; P = 0.004) more frequently than children in either program. Few differences in intake were observed for mothers or children participating in only WIC or SNAP vs both programs or neither program.Conclusion and ImplicationsHouseholds participating in both WIC and SNAP may benefit from additional policy and programmatic interventions to limit sugar-sweetened beverage intake and reduce spending on bottled water.     

The Special Supplemental Nutrition Program for Women,Infants, and Children Spillover Effect: Do Siblings Reap the Benefits?

BackgroundParticipation in the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC) among 0- to 5-year-old children is associated with healthier diets. Extension of dietary benefits to older, age-ineligible children (5-18 years old) residing in WIC households has not been fully investigated.ObjectiveExamine the association between household WIC participation and dietary behaviors of age-ineligible children.DesignCross-sectional secondary analysis of data collected from 2 independent panels (2009-2010 and 2014) of the New Jersey Child Health Study, using household surveys. Questions derived from national surveys assessed consumption frequency of specific foods among 5- to 18-year-old children.Participants/settingThe analytic sample included 616 age-ineligible children from households with incomes below 200% of the federal poverty level, 398 of whom were from WIC-participating households.Main outcome measuresEating behaviors were measured as frequency of daily consumption of fruit, vegetables, 100% juice, sugar-sweetened beverages, and sweet and salty snacks.Statistical analysisMultivariable negative binomial models examined the association between eating behaviors and household WIC participation status adjusting for child’s age, sex, and race; mother’s education; city of residence; household size; and panel. Results are expressed as incidence rate ratios (IRRs).ResultsHousehold WIC participation was not associated with dietary behaviors among age-ineligible children (5-18 years old) in the overall sample. However, healthier dietary patterns were observed for specific demographic groups. Compared with age-ineligible children in non-WIC households, age-ineligible children in WIC households had (1) a higher frequency of vegetable consumption among 12- to 18-year-old children (IRR = 1.29; 95% confidence interval [CI] 1.05-1.58; P = .015); (2) a marginally significant higher frequency of 100% juice consumption among females (IRR = 1.27; 95% CI 1.00-1.62; P = .053); and (3) a lower frequency of sugar-sweetened beverages consumption among Hispanic children (IRR = 0.61; 95% CI 0.43-0.86; P = .004).ConclusionsHousehold WIC participation may positively influence dietary behaviors of age-ineligible children, suggesting a possible WIC spillover effect. Revisions to WIC package composition should consider the possible dietary implications for all children in the household.     

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

ObjectiveExamine 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.MethodsCross-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.ResultsAmong 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 ImplicationsIn 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.     

SNAP-Ed Policy,Systems, and Environmental Interventions and Caregivers’ Dietary Behaviors

ObjectiveTo examine dietary behaviors and diet quality among caregivers of children regarding the number of policy, systems, and environmental (PSE) change interventions implemented in their neighborhoods.MethodsHouseholds with incomes ≤185% of the federal poverty level were randomly sampled throughout California. A validated 24-h dietary recall assessment tool was administered by telephone. The independent variable was the number of Supplemental Nutrition Assistance Program Education PSE change interventions per census tract where the caregivers lived.ResultsMost (69.1%) of the 2,222 caregivers were Latino. Policy, systems, and environmental reach predicted decreased intake of sugar-sweetened beverages (P = 0.022, Cohen d = −0.12) and added sugar (P = 0.014, Cohen d = −0.18), and increased Healthy Eating Index–2015 scores (P = 0.046, Cohen d = 0.18), regardless of race and/or ethnicity, age, or reach of Supplemental Nutrition Assistance Program Education direct education.Conclusions and ImplicationsReplication of these methods and findings, and comparisons of dietary outcomes in association with PSE change interventions with and without direct education activities aimed at the same population under study, are encouraged.     

An Increase in SNAP Benefits Did Not Impact Food Security or Diet Quality in Youth

BackgroundLow diet quality during childhood and adolescence is associated with adverse health outcomes later in life. Diet quality is generally poor in American youth, particularly in youth of low socioeconomic status. The Supplemental Nutrition Assistance Program (SNAP) is the primary safety net to help low-income households afford a healthy diet. Yet self-selection into the program creates challenges in estimating the relationship between SNAP and diet outcomes.ObjectiveThis study examined how the increase in SNAP benefits during the American Recovery and Reinvestment Act (ARRA) affected food security and diet quality in low-income youth.DesignThis analysis used a difference-in-differences design and data from the National Health and Nutrition Examination Survey 2007-2008 to 2011-2012 waves.Participants/settingThe sample included children and adolescents aged 2 to 18 years with household income ≤250% of the Federal Poverty Line. Food security and diet outcomes in SNAP-eligible youth (n = 2,797) were examined, with children in nearly SNAP-eligible households serving as a comparison group (n = 1,169). The diet quality analysis stratified the sample by age range.Main outcome measuresThe study assessed food security and 6 dietary outcomes: 2 nutrients (sodium and fiber), 3 food categories (fruit, vegetables, and sugar-sweetened beverages), and 1 measure of overall diet quality (Healthy Eating Index 2010).Statistical analysis performedLogistic regression and linear regression were used to estimate the relationship between SNAP eligibility and child food security and diet.ResultsIn unadjusted analysis, approximately 64% of SNAP-eligible children were food secure before ARRA and 73% were food secure while ARRA was in effect. Using logistic regression in a difference-in-differences framework, the ARRA SNAP benefit increase was not significantly associated with food security (odds ratio 1.37, P = 0.43). Diet quality of SNAP-eligible children was low, scoring a 46 out of 100 on the Healthy Eating Index 2010. Measures of diet quality did not significantly change from the pre-ARRA period to the ARRA period; this did not differ by age range.ConclusionsThe increase in SNAP benefits during ARRA did not significantly impact food security or diet quality in low-income children and adolescents. Additional research to better understand how SNAP benefits impact dietary choice is warranted.     

Differences in a Chain Supermarket's Sales to SNAP Shoppers Before and Since the COVID-19 Pandemic

ObjectiveThis study 1) compares grocery sales to Supplemental Nutrition Assistance Program (SNAP) shoppers in rural and urban grocery stores and 2) estimates changes in sales to SNAP shoppers in North Carolina (NC) since the pandemic.DesignWeekly transaction data among loyalty shoppers at a large grocery chain across NC from October 2019 to December 2020 (n = 32; 182 store weeks) to assess nutritional outcomes.SettingNorth Carolina large chain grocery stores.ParticipantsLarge chain grocery store/SNAP shoppers.InterventionRural/urban status of the stores and COVID-19 pandemic onset.Main Outcome MeasuresShare of total calories sold from fruits, vegetables, nuts, and legumes (FVNL) with and without additives, sugar-sweetened beverages (SSB), less healthful foods (LHF), and processed meats (PM).AnalysisMultivariate random effects models with robust standard errors to examine the association of rural/urban status before and since coronavirus disease 2019 with the share of calories sold to SNAP shoppers from each food category. We controlled for county-level factors (eg, sociodemographic composition, food environment) and store-level factors.ResultsWe did not find significant rural-urban differences in the composition of sales to SNAP shoppers in adjusted models. There was a significant decrease in the mean share of total calories from sugar-sweetened beverages (−0.43%) and less healthful food (−1.32%) and an increase in the share from processed meats (0.09%) compared with before the pandemic (P < 0.05).Conclusions and ImplicationsUrban-rural definitions are insufficient to understand nuances in food environments, and more support is needed to ensure healthy food access.     

Connecting Families at Risk for Food Insecurity With Nutrition Assistance Through a Clinical-Community Direct Referral Model

ObjectiveTo assess the feasibility of a clinical-community direct referral model to enroll eligible households in the Supplemental Nutrition Assistance Program (SNAP).MethodsPediatric clinics screening for food insecurity (n = 27) invited families experiencing food insecurity to participate in a direct referral to a local organization that assists with SNAP applications. A food stamp specialist telephoned participants to determine SNAP eligibility, assist with the application, and/or provide other supports. Referrals, eligibility determination, enrollment, and estimated benefits were tracked.ResultsA total of 486 families were referred to the community partner; 72% (n = 351) were successfully contacted by a food stamp specialist, with 17% (n = 83) applying for SNAP benefits. Another 16% (n = 79) were already enrolled in SNAP but received an additional service.Conclusions and ImplicationsThis referral model was feasible and increased the number of families who received nutrition assistance. This approach could be adapted for other health-related social needs.     

Participation in the Supplemental Nutrition Assistance Program and Dietary Behaviors: Role of Community Food Environment

BackgroundThe United States Department of Agriculture’s Supplemental Nutrition Assistance Program (SNAP) is the country’s largest nutrition assistance program for low-income populations. Although SNAP has been shown to reduce food insecurity, research findings on the diet quality of program participants are inconsistent.ObjectiveThis study evaluated whether the community food environment is a potential moderator of the association between SNAP participation and eating behaviors.DesignThis cross-sectional study used participant data from a telephone survey of 2,211 households in four cities in New Jersey. Data were collected from two cross-sectional panels from 2009 to 2010 and 2014. Food outlet data were purchased from commercial sources and classified as supermarkets, small grocery stores, convenience stores, or limited service restaurants.Participants/settingAnalysis is limited to 983 respondents (588 SNAP participants) with household incomes below 130% of the federal poverty level.Main outcome measuresEating behaviors were assessed as frequency of consumption of fruit, vegetables, salad, and sugar-sweetened beverages.Statistical analyses performedInteraction and stratified analyses using gamma regression determined the differences in the association between SNAP participation and eating behaviors by the presence or absence of food outlets adjusted for covariates.ResultsSNAP participation was associated with a higher frequency of consuming sugar-sweetened beverages (P<0.05) when respondents lived within ¼ to ½ mile of a small grocery store, supermarket, and limited service restaurant. SNAP participants who did not live close to a convenience store reported a lower frequency of sugar-sweetened beverage consumption (P=0.01), and those living more than ½ mile away from a supermarket reported a lower frequency of fruit consumption (P=0.03).ConclusionsThe findings from this study suggest that the community food environment may play a role in moderating the association between SNAP participation and eating behaviors. Although SNAP participation is associated with some unhealthy behaviors, this association may only hold true when respondents live in certain food environments.     

Dietary Intake Changes in Response to a Sugar-Sweetened Beverage Reduction Trial for Various Supplemental Nutrition Assistance Program (SNAP) Eligibility Groups

Objective

To examine dietary intake differences resulting from a sugar-sweetened beverage reduction intervention by 3 Supplemental Nutrition Assistance Program (SNAP) participation groups: SNAP participants (n?=?56), income-eligible nonparticipants (n?=?30), and income-ineligible nonparticipants (n?=?60).

Diet Quality and Fruit,Vegetable, and Sugar-Sweetened Beverage Consumption by Household Food Insecurity among 8- to 12-Year-Old Children during Summer Months

BackgroundSchool-delivered nutrition assistance programs have improved dietary intake for children from food-insecure households during the school year. However, little is known about their diet quality and eating patterns during summer months.ObjectiveSchool-aged children’s summer month weekday and weekend day diet quality and eating patterns were assessed by household food insecurity.DesignSecondary analysis of cross-sectional data was employed.Participants/settingDuring the summers of 2011 through 2017, baseline data were collected from parent–child dyads participating in one of two community-based obesity prevention trials in metropolitan Minnesota (N=218). The mean age of children was 10 years; 50% were girls, 49% were nonwhite, and 25% were from food-insecure households.Main outcome measuresChildren from food-secure and food-insecure households were identified by using the short form of the US Household Food Security Survey. Healthy Eating Index 2015 and eating patterns—including energy intake and consumption of whole fruits, vegetables, 100% fruit/vegetable juice, and sugar-sweetened beverages—were estimated by means of 24-hour dietary recall interviews conducted on weekdays and weekend days.Statistical analysis performedGeneral linear modeling was used to examine diet quality and eating patterns by food insecurity, controlling for child age, child body mass index z score, and parent education.ResultsChildren from food-insecure and food-secure households had Healthy Eating Index 2015 scores less than 50. Children from food-insecure households reported less energy intake, fewer cups of whole fruit, and more sugar-sweetened beverage consumption for every 1,000 kcal consumed on a weekend day when compared with their counterparts from food-secure households (P<0.05). Similar results were not seen for weekday eating patterns.ConclusionsWhole fruit and sugar-sweetened beverage consumption varied by food insecurity on weekend days during summer months. Because children tend to gain weight during summer months, efforts to increase weekend access to whole fruits and promote water consumption may contribute to weight gain prevention and healthy development, especially for children from food-insecure households.     

Few Changes in Food Security and Dietary Intake From Short-term Participation in the Supplemental Nutrition Assistance Program Among Low-income Massachusetts Adults

ObjectiveTo 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.MethodsA 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.ResultsSupplemental 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 ImplicationsPolicies 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.     

Hunger or Deportation: Implications of the Trump Administration's Proposed Public Charge Rule

Until recently, lawfully present noncitizens participating in the US Department of Agriculture Supplemental Nutrition Assistance Program (formerly Food Stamps) faced no immigration consequences. However, in September, 2018, the Trump Administration proposed a more expansive public charge rule in the Federal Register that would deny lawfully present noncitizens a path to citizenship if they had participated in certain federal safety net programs, including Supplemental Nutrition Assistance Program. This perspective discusses the proposed rule's implications, particularly for those with professional interests in promoting effective nutrition education and healthy behavior through research, policy, and practice among individuals who will potentially be affected.     

Use of Survival Analysis to Predict Attrition Among Women Participating in Longitudinal Community-Based Nutrition Research

ObjectiveTo identify participant characteristics and study methodology that influenced the completion of a 15-month community-based longitudinal study evaluating the impact of the Supplemental Nutrition Assistance Program Education and Expanded Food and Nutrition Education Program.DesignObservational longitudinal 15-month study across 12 data collection timepoints. Sociodemographic characteristics were collected with a paper-based survey at baseline.SettingFive counties across central and southern Illinois.ParticipantsWomen, aged 18 to 65 years (n = 297), recruited at sites likely to serve families eligible for the Supplemental Nutrition Assistance Program Education and Expanded Food and Nutrition Education Program (housing departments, child care centers, etc).Main Outcome MeasuresPredictors of participant attrition during the study duration.AnalysisCox proportional hazard models.ResultsNinety-seven participants were retained across the full study. In unadjusted models, greater income and education levels were significantly related to lower attrition; however, this relationship did not persist in a multivariate model. When adjusted for other characteristics, larger household size was the only measured variable significantly related to greater odds of attrition (odds ratio = 1.09; 95% confidence interval = 1.02, 1.17).Conclusions and ImplicationsSeveral characteristics predicting attrition in other settings were not significant in this study. Future attrition analyses that evaluate social support, transportation capacity, and type of phone in longitudinal nutrition education studies are warranted.     

Plate Waste in School Lunch: Barriers,Motivators, and Perspectives of SNAP-Eligible Early Adolescents in the US

ObjectiveTo determine barriers, motivators, and perspectives regarding plate waste reduction of early adolescents.DesignTrained interviewers conducted audio-recorded individual interviews with adolescents.SettingElementary schools implementing the National School Lunch Program in Hawai‘i, Montana, and Virginia.ParticipantsEarly adolescents (n = 47, aged 9–13 years) from families receiving or eligible to receive Supplemental Nutrition Assistance Program benefits were recruited to participate.Phenomenon of InterestFactors influencing plate waste among adolescents and potential plate waste reduction strategies.AnalysisCoders analyzed content and thematic data to identify code categories and themes.ResultsMain barriers to reducing school lunch plate waste were unsupportive school policy, undesirable food quality, satiation, and social influences. Key motivators to reducing school lunch plate waste were supportive school policy, including allowing students to share food with peers and save food to eat later; and social influences. Participants found it acceptable to throw away disliked food and unacceptable to throw away wanted food; they perceived that their peers did not care whether food was thrown away; and they thought their parents disliked wasting food.Conclusion and ImplicationsResults suggest that several factors might allow for minimization of school lunch plate waste in the National School Lunch Program, including improvements in food quality, food policy, and social influences. Under these important themes, strategies to employ may include improving food preparation and taste, allocating more time for students to finish lunch, allowing students to self-select food lunch items, and permitting them to share and save their leftover food.     

Effectiveness of Expanded Food and Nutrition Education Program in Changing Nutrition-Related Outcomes Among Adults With Low Income: A Systematic Review

ObjectiveTo review the effect of the Expanded Food and Nutrition Education Program (EFNEP) in changing nutrition-related outcomes.MethodsRelevant research conducted before December 2020 was identified using PubMed, Web of Science, Google Scholar, and the EFNEP Research Database. The methodological quality of each eligible study was assessed.ResultsOf the 406 studies found, 30 were eligible; 26 studies were on EFNEP, and 4 included both EFNEP and Supplemental Nutrition Assistance Program Nutrition Education (SNAP-Ed). The sample sizes ranged from 35 to 122,961. Outcome measures included consumption of food groups, nutrients, other nutrition-related behaviors, and food security. At least 1 immediate behavior change (P < 0.05) was reported in each study, but long-term maintenance of behavior change was not evident.DiscussionThis review found a consistent, immediate improvement in nutrition behaviors after program participation but poor retention over time. Overall, variation in programming and outcome measures, incomplete reporting, and generally low study quality by modern standards precluded strong conclusions.Implications for Research and PracticeThis review identified the need for control groups, improved reporting of program protocols, theory-based curriculum, and measurement of long-term outcomes.     

Impact of Food Insecurity Nutrition Incentives on Household Fruit and Vegetable Expenditures

ObjectiveEvaluate the impact of the Food Insecurity Nutrition Incentive (FINI) grant program on self-reported fruit and vegetable (FV) expenditures.DesignPre-post quasi-experimental study design.SettingFarmers markets and grocery stores in states with FINI projects.ParticipantsA total of 2,471 Supplemental Nutrition Assistance Program (SNAP) households in 4 intervention groups who lived near a FINI retailer (farmers market or grocery store) and 4 matched comparison groups who did not live near a FINI retailer.Main Outcome MeasuresAwareness and use of point-of-sale incentives and changes in self-reported monthly household FV expenditures.AnalysisOrdinary least squares intent-to-treat regression model using lagged dependent variable model framework.ResultsAwareness of FINI was higher among households who were near a FINI retailer and had shopped there before FINI than those who lived near a FINI retailer but had not shopped there before FINI; the number of information sources from which SNAP participants heard about FINI was positively associated with incentive receipt (P < 0.05). Among those who received incentives, the average amount of incentives received at the last shopping trip ranged from $15 to $23. The FINI program had a positive impact on the average monthly FV expenditures for those in the farmers market shopper, grocery store shopper, and grocery store general intervention groups—increases ranged from $9 to $15 (P < 0.05).Conclusions and ImplicationsPoint-of-sale incentives were associated with an increase in FV expenditures among SNAP households. Further research is needed to examine (1) effective messaging strategies to increase incentive awareness and (2) the long-term impact of incentives on FV expenditures.     

Caloric Beverage Intake Among Adult Supplemental Nutrition Assistance Program Participants

Objectives. We compared sugar-sweetened beverage (SSB), alcohol, and other caloric beverage (juice and milk) consumption of Supplemental Nutrition Assistance Program (SNAP) participants with that of low-income nonparticipants.Methods. We used 1 day of dietary intake data from the 2005–2008 National Health and Nutrition Examination Survey for 4594 adults aged 20 years and older with household income at or below 250% of the federal poverty line. We used bivariate and multivariate methods to compare the probability of consuming and the amount of calories consumed for each beverage type across 3 groups: current SNAP participants, former participants, and nonparticipants. We used instrumental variable methods to control for unobservable differences in participant groups.Results. After controlling for observable characteristics, SNAP participants were no more likely to consume SSBs than were nonparticipants. Instrumental variable estimates showed that current participants consumed fewer calories from SSBs than did similar nonparticipants. We found no differences in alcoholic beverage consumption, which cannot be purchased with SNAP benefits.Conclusions. SNAP participants are not unique in their consumption of SSBs or alcoholic beverages. Purchase restrictions may have little effect on SSB consumption.People in the Unites States consume about 20% of their calories from beverages, a share that has increased greatly over recent decades.1 Calories from beverages may be less satiating than calories from food and may therefore contribute to weight gain.2–5 Calories from sugar-sweetened beverages (SSBs) may be particularly problematic because they provide little if any essential nutrients. Policies suggested or enacted to reduce SSB consumption include taxing SSB purchases6–9 and restricting the size of SSBs sold by food service establishments. Most recently, the discussion has moved to whether participants in the Supplemental Nutrition Assistance Program (SNAP) should be prohibited from using benefits to purchase SSBs. SNAP provides nutrition assistance to low-income individuals and families through electronic benefit transfer cards that can be used to purchase food at authorized food retailers. SNAP benefits can be used to purchase almost all foods, with the exceptions of hot foods or food that will be eaten in the stores, alcoholic beverages and tobacco products.New York City requested a waiver from the Food and Nutrition Service of the US Department of Agriculture to restrict the use of SNAP benefits for purchases of some SSBs10 but was denied. Several high-profile commentators argued that the SNAP program may be subsidizing obesity and should be modified to encourage greater consumption of healthy foods and reduced consumption of empty calories such as SSBs.11,12 Others have argued that such restrictions could increase administrative costs but would have little impact on consumption patterns because most participants’ SNAP benefit only covers a portion of the household’s total food spending, and they could just use their cash food budgets to purchase SSBs.13 It has also been argued14 that imposing restrictions on only 1 part of the population is unfair when consumption of SSBs and obesity are fairly widespread among all Americans. Restrictions on SNAP purchases could have unintended consequences, such as reducing participation or substitution with other energy-dense foods.Despite the prominent appeals to restrict SNAP participants’ purchases, little evidence has shown that SNAP participants’ SSB consumption is different from that of the average consumer or other low-income consumers. Using longitudinal data for a cohort of US youths, no differences were found between SNAP participants and otherwise similar nonparticipants in the frequency of consumption (not total calories) of soft drinks, 100% fruit juice, and milk.15 Purchases of different beverages at 1 chain grocery store in New England for a sample of families that participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program over a 2-year period showed that among the participants, those who also received SNAP benefits purchased a higher percentage of SSBs than did non-SNAP participants.16 This study did not consider all SNAP households (or any other low-income households that did not participate in either SNAP or the Special Supplemental Nutrition Program for Women, Infants, and Children); examined beverage purchases at only 1 grocery store chain in New England; did not consider beverage purchases at bars, restaurants, or other food retailers; and did not consider beverage intake among household members. Both of these studies examined only a segment of all SNAP participants.Alcoholic beverages contribute a sizable share of total beverage calories for those who consume them. Alcoholic beverages cannot be purchased with SNAP benefits. If SSB purchases are restricted in SNAP, participants could use other resources to purchase SSBs, just as they may to purchase alcoholic beverages. Although there are important distinctions between SSBs and alcohol (e.g., tax rates, controlled points of purchase, limits on who can purchase, and some health benefits of moderate consumption), examining how alcohol consumption differs between participants and nonparticipants may provide insight into how a restriction on SSBs could affect purchases among SNAP participants.We used national-level data on individual beverage intake to investigate intake of SSBs, alcohol, and other caloric beverages (milk and juice) for SNAP participants and otherwise similar nonparticipants. After comparing average intake of these beverage types, we used regression to explore whether differences across participant groups are explained by differences in observable characteristics. We separately estimated the probability of consuming each beverage type and the total number of calories consumed among consumers of each beverage. We augmented our main estimates with instrumental variable estimates that account for self-selection of SNAP participants.