Chicuén 1 María Cristina Chicuén Professor Lisa Goldman Rosas HumBio 123: Obesity in America 13 March 2015 (SNAP)ing out of obesity: Analyzing the relationship between supplemental nutrition assistance programs and obesity in America Introduction Obesity, poverty, and malnutrition epidemics are currently sweeping the United States, primarily affecting low-income communities living at or below 130% of the poverty level, as per federal guidelines. Due to a lack of financial resources, low-income individuals seek help from various supplemental assistance programs funded by the government, such as the Supplemental Nutrition Assistance Program (SNAP), whose aim is to provide nutritional support to individuals and families by creating a safety net against domestic hunger. Although programs like SNAP have been instrumental in delivering food aid to those in need, these measures have not adequately addressed an issue that is closely tied to poverty and SNAP: obesity. While a direct relationship between SNAP and obesity has not been established due to the individual, case-bycase nature of this connection, there have been epidemiological studies that have examined how SNAP benefits have been used to purchase energy-dense foods high in refined grains, sugars, and fats that are relatively cheaper in comparison to healthier alternatives (Kupillas & Nies, 2007). The interconnectedness of obesity and poverty poses a clinical and public health challenge seeing as though 68.5% of American adults are overweight or obese and approximately 14% of families receive help from SNAP (Levi, Segal, Laurent, & Rayburn,

Chicuén 2 2014). Moreover, in a study published by Alston et al – Likely Effects on obesity from proposed changes to the US food stamp program – researchers discussed how SNAP participants “are more likely to suffer from iron deficiencies and anemia than higher-income and eligible nonparticipants.” Costs associated with programs created to address these problems are rounding $270 billion, $190 billion coming from obesity-related costs and $80 billion from SNAP expenditures (Economic Costs, HSPH 2012). This matter of contention has had cascading effects in areas not immediately involved, such as schools and the workplace, and have longstanding social repercussions that affect an individual’s ability to interact with their micro and macro communities. This paper will analyze publications that have sought to examine the relationship between supplemental food assistance programs and obesity, ranging from state-specific studies to national data, and will incorporate recommendations to improve the current structure of SNAP to better accommodate and facilitate access to nutritional options to reduce the perpetuation of obesity among SNAP recipients. Method As mentioned above, this literature review seeks to explore the intersection of supplemental food assistance programs and the prevalence of obesity among SNAP recipients. Throughout my research, I did not set out to examine causal relationships between SNAP and obesity but rather investigate if there was significant literature pertaining to this topic. I focused on publications that discussed the association between obesity and supplemental nutritional assistance programs and how these were not equipped with the proper tools households need to fulfill dietary requirements and federal nutritional recommendations. To provide solutions to the lack of healthy food sources SNAP holders can access given their limited funds, this paper also examines articles that discuss innovative ways SNAP programs are being redesigned to increase

Chicuén 3 use of SNAP benefits at farmer’s markets, quality supermarkets as opposed to convenience stores, and other localities that promote sustainable, healthy eating behaviors. Due to the specificity of this topic, finding literature that described the relationship between supplemental food assistance programs and obesity was difficult because there were articles that focused primarily on the economic issues behind SNAP and did not comment on the direct effects SNAP has on obesity. Also, some literature was not used because of the target population examined; the purpose of the review was to evaluate the effects of SNAP on obesity among all participants as opposed to just focusing on children and adolescents. Other articles, such as those describing the impact of food environments and general food insecurity patterns, were not used in this literature review because they did not directly discuss the effects of these on both SNAP and obesity. Results I.

State-specific Studies Among the articles chosen for review, three focused on the association between SNAP

and obesity. One case study – Is participation in food and income assistance programmes associated with obesity in California adults? Results from a state-wide survey – followed California adults (n=7741) whose household income was at or below 130% of the federal poverty level. The main objective of this study was to examine how BMI and obesity was affected by participation in SNAP, Supplemental Security Income (SSI), or Work Opportunities and Responsibilities to Kids (CalWorks) among low-income beneficiaries and non-beneficiaries. Researchers used data from the 2007 California Health Interview Survey (CHIS), a populationbased, random-digit-dial telephone survey to determine these relationships. Examples of the questions participants were asked included “Are you receiving food stamp benefits?” and other

Chicuén 4 questions pertaining to food insecurity (e.g. consumption of French fries, fruits, and soda versus vegetable intake). After the data was analyzed, the results showed that 27.4% of participants were obese, with the highest obesity rate coming from adults aged 30-49 with less than 12 years of formal education, living in a household with six or more people, and with high incidence of food insecurity (Leung & Villamor, 2010). A key result from this study was that the prevalence of obesity was 30% higher among SNAP participants when compared to non-participants. When operationalized for gender, men receiving SNAP benefits had a 61% higher rate of obesity than women. These findings led researchers to think about the “food stamp cycle” that may be leading to the high rates of obesity among low-income groups. The “food stamp cycle” refers to “a cycle where monthly receipt of SNAP benefits may encourage periods of binge eating followed by energy restriction among its participants.” The pervasiveness of food insecurity among these populations is another crucial element to consider because those who lack adequate food sources are more likely to be obese or inadequately fed, meaning that SNAP benefits may not be the sole determinant of obesity. This state-specific study thus opens the field to further research about dietary quality among low-income populations, especially those receiving federal food aid. Another study – Low-income Supplemental Nutrition Assistance Program participation is related to adiposity and metabolic risk factors – focused on national data gathered from the National Health and Nutrition Examination Surveys (NHANES) from 2003-2006 to determine whether SNAP participation was positively associated with obesity. The study population (n=2250) was restricted to low-income households (<130% of federal poverty level) and used BMI, waist circumference, and metabolic risk factors as its main outcome measures. From this nationally representative sample, researchers gathered that among those SNAP participants, 23.7% were overweight and 44% were obese. SNAP participation was also positively associated

Chicuén 5 with BMI, lower HDL cholesterol, and elevated fasting glucose, among others (Leung, Willett, & Ding, 2011). This study also took into account the rising poverty rate in the United States. Since those living in poverty rely heavily on SNAP and other food aid programs, the findings from this study support the need to revise the structure of SNAP, especially in the area of promoting healthy dietary behaviors. Both studies discussed above mentioned food insecurity as a recurring problem among SNAP recipients and how this factor can mediate the link between SNAP and obesity. In this next study – Supplemental Nutrition Assistance Program participation did not help low income Hispanic women in Texas meet the dietary guidelines – researchers examined the association between SNAP participation and dietary intake between Hispanic women (n=661) living in Texas, taking into account the prevalence of food insecurity in these communities. Researchers hypothesized that participation in SNAP would lead to improved dietary intake when compared with non-SNAP beneficiaries. Participants were part of an intervention that was incorporated into the Texas Expanded Food and Nutrition Education Program (EFNEP), which is a federal program that helps low-income families learn the necessary skills to eat a well-balanced diet. Among the 661 Hispanic women, 27% participated in SNAP programs and 83.9% of these women were overweight or obese. Focusing on SNAP participation and dietary recommendations, SNAP participants did not meet the recommended guidelines, consuming less amounts of dietary fiber, vitamin D, iron, and Vitamin A (Hilmers et al., 2014). Among this sample, SNAP participants showed greater intake of processed sugars and lower intake of whole grains. While these findings did not allow researchers to establish a direct link between SNAP and obesity, it did indicate that the diets of Hispanic women participating in SNAP programs had poorer diets when compared to non-SNAP participants. This finding is key because it refutes the

Chicuén 6 foundation of SNAP, which claims to “enhance the overall dietary quality of low-income populations by increasing their food purchasing power.” However, the three studies summarized above have shown that SNAP participants have very little purchasing power in the area of healthy foods. II.

Public Policy Recommendations After reviewing arguments favoring and opposing the relationship between SNAP and

obesity, one clear issue still remains unsolved: how to restructure SNAP so that it facilitates access to healthier food options and eating practices. Policymakers have taken into consideration the gaps that exist within SNAP and have moved to improve the program. Before submitting policy recommendations to the USDA, Long et al. administered a study – Public support for policies to improve the nutritional impact of the Supplemental Nutrition Assistance Program (SNAP) – to gather public support for policies intended to improve SNAP. The study primarily focused on 1) gauging participants feelings towards the federal budget allotted towards SNAP and 2) whether participants supported policies targeting SNAP’s nutritional impact. The study involved a four-question, randomized phone-survey supplemented to an ongoing Harris Interactive Poll administered by researchers at the Harvard School of Public Health to 3024 adults; 418 of these participants had received SNAP benefits within the last twelve months. This poll primarily focused on gathering attitudes concerning support for governmental spending on SNAP-like initiatives and other farming programs. The results showed that 77% of participants approved of federal spending on SNAP (48% support an increase in spending, 29% support maintaining current budget). The proposed nutritional policies were also received positively; 82% of participants backed policies aimed at providing “additional money to SNAP participants that can only be used on fruits, vegetables or other healthful foods (Long et al., 2014).

Chicuén 7 Participants were not overwhelmingly in favor of giving “SNAP participants more food stamp dollars to guarantee that they can afford a healthy diet.” 54% of SNAP participants were in favor of removing sugary drinks from SNAP benefits; the 46% who were not in favor were willing to reconsider this option if the removal of sugary drinks were complemented with extra benefits that would facilitate the purchase of healthier foods (e.g. fruits and vegetables). This study is a significant indicator of potential policy changes that the USDA can incorporate into the existing SNAP structure keeping in mind the effects these changes can have on the current obesity epidemic. While the data gathered from the Harvard School of Public Health was based on hypothetical changes, states have started implementing changes to their food assistance programs to increase access to healthier options. The Division of Nutrition, Physical Activity and Obesity (DNPAO) funded a review of the New York City Health Bucks program, an initiative focused on incentivizing SNAP recipients to shop at farmer’s markets through the use of coupons. In this study – Implementing a Farmers’ Market Incentive Program: Perspectives on the New York City Health Bucks Program – participants receive $2 coupons, namely Health Bucks, from community groups and District Public Health Offices (DPHOs) that “are redeemable for the purchase of locally grown fresh fruits and vegetables at farmer’s markets in the South Bronx, North and Central Brooklyn, and East and Central Harlem.” SNAP beneficiaries can receive an extra $2 for every $5 spent at farmer’s markets accepting Electronic Benefit Transfer payment. During the distribution process, community based organizations (CBOs) provided nutrition education and promoted awareness of the benefits offered by farmer’s markets. The main focus of this study was to assess the impact of using Health Bucks at farmer’s markets on subsequent fruit and vegetable consumption. Post-completion, researchers found that SNAP recipients

Chicuén 8 increased their use of Health Bucks from 3,000 coupons in 2005 to 138,930 coupons in 2010, a 46-fold increase (Payne et al., 2013). While this study did not record the responses of SNAP users at farmer’s markets, the Health Bucks initiative was well received by farmer’s market staff. Approximately 75% of vendors agreed that Health Bucks contributed to increased revenue; 72% said that they sold more fresh fruits and vegetables after the initiative (Payne et al., 2013). Although more research is required to determine the effectiveness of Health Buck-type programs on a national scale, it can be assumed that programs that facilitate the access to healthier food options through coupons and incentives will be received positively among SNAP users as well as organizations that would likely receive some type of subsidy for their participation in a federally backed assistance program. Before programs similar to Health Bucks start appearing across the United States, there needs to be a massive restructuring of the food environment in areas commonly known as food deserts. States need to find ways to reduce consumption barriers in low-income communities that do not have farmer’s markets in their area. The effort to reduce obesity and other health disparities among SNAP beneficiaries will greatly benefit if policy makers and urban planners tackle these issues. Researchers have also studied the effects of terminating SNAP subsidies for sugarsweetened beverages (SSBs) and how this affects food choices among SNAP users. The study by Basu et al. – Ending SNAP Subsidies For Sugar-Sweetened Beverages Could Reduce Obesity And Type 2 Diabetes – set out to see if removing SNAP subsidies for SSBs coupled with an initiative similar to the Health Bucks platform would affect obesity and Type 2 diabetes. Data was gathered using twenty-four hour dietary recall from SNAP participants in the National Health and Nutrition Examination Survey (NHANES) to measure food consumption and linked this information to price data among thirty-five market areas provided by Nielsen Homescan

Chicuén 9 Panel Data. Using these databases side-by-side permitted researchers to estimate “how a change in the price of a food time affects subsequent consumption and how a change in the price of a food affects substitution of that food with other foods.” The results from this study showed that placing a ban on SSBs would reduce caloric intake per SNAP participant by 25.5 kcal per day. Since SNAP benefits could no longer be used to purchase SSBs, researchers concluded that participants would either 1) use their own disposable income to purchase them or 2) purchase SNAP-subsidized beverages like fruit juices (Basu et al., 2014). In the long-term, these effects could reduce obesity rates by 0.89% among SNAP participants. The simulation that mirrored the Health Bucks initiative did not prove to have a significant impact on overall caloric intake of fruits and vegetables. The results from this study allowed researchers to make sizable projections about the effects these policies would have on obesity prevention and consumption of healthier food items. According to the simulated data, obesity prevalence post-SSBs ban would decrease by over 281,000 in adults and 141,000 in children. Although the data brought forth by this study is promising, there still remains a practicality issue pertaining to the economic challenges banning SSBs could bring. I foresee immense lobbying by soda makers to keep SSBs subsidized by SNAP since this brings in billions of dollars to SSB providers. Nevertheless, this study supports prior calls for policy change relating to SNAP, especially in the area of eliminating the components that are scientifically proven to promote obesity and other health risks. Discussion Based on the evidence provided by the articles reviewed, reforming SNAP’s structure could lead to a decrease in the prevalence of obesity in the United States. The data brought forth form state-specific studies, such as the CHIS study in California, showed that when compared to non-SNAP participants, the incidence of obesity was 30% higher amid SNAP participants.

Chicuén 10 Although the data came from one sample of participant in California, the results still hold an adequate level of external validity because SNAP programs are designed similarly across the nation. If this trend still occurs after a nationally representative study has taken place, it would seem necessary for the USDA and health officials to further review the foods beneficiaries can purchase. A proposed change can include a limit to the amount of SSBs participants may purchase or an overall decrease in the benefits allotted towards processed foods. Although researchers have said that imposing bans on unhealthy merchandise can lead to feelings of discrimination or social stigma among SNAP recipients, officials will have to evaluate what option will lead to the most desirable health outcome in the long-term. A way to reduce the incidence of unhealthy purchases is to increase the availability of high quality merchandise that SNAP recipients can access. The increasing number of food deserts across the nation promotes the practice of unhealthy food purchases simply because SNAP recipients have no other option but to buy low-quality, processed foods from convenience stores and underserved supermarkets. Although efforts like Health Bucks are positive steps toward reducing the food access gap through promotion of farmer’s markets, this initiative alone will not solve the overarching problem: farmer’s markets are not a common occurrence in lowincome neighborhoods. If policymakers want to encourage the use of coupons at farmer’s markets among SNAP recipients, urban planners need to get involved in providing the necessary infrastructure for vendors to set up their individual shops and provide for these communities in need. The overall impact of Health Buck-type programs will significantly increase if these measures are introduced together. If these recommendations are implemented and obesity rates do not change even after SNAP participants have access to healthier food options, then the obesity problem might not be correlated with food choices and could thus point to other areas of

Chicuén 11 concern, such as a lack of physical activity, among others. Nevertheless, the fact that these programs are being adopted across several states indicates that there is interest in improving the access to healthier food choices for SNAP recipients. The studies reviewed suggest that researchers have been increasingly interested in demonstrating how much the national public supports SNAP reforms. Taking into consideration that SNAP receives 12% of the federal budget, which includes taxpayer money, policymakers need to incorporate public recommendations into upcoming reforms. This is a problematic issue because if specific reforms, like removing soda from SNAP benefits, have any hope of passing, there needs to be a strong lobbying group to counter the efforts of companies like Coca Cola, who have a high stake in keeping their SNAP share since taxpayers subsidize approximately $4 billion worth of soda products annually. Congress and those involved in making these decisions need to understand the health consequences of these financially driven choices. Soda products contradict SNAP’s attempt to provide healthier options to consumers. Like alcohol and tobacco products, SSBs are not a crucial component of a healthy diet. Rather, the money used to keep SSBs on the list of permitted SNAP items should be used to fund the purchases of fruits and vegetables or other foods that have a significant nutritional impact. The literature presented throughout this review addresses key topics that are instrumental in analyzing the relationship between SNAP and obesity. While the data presented above was sufficient to conclude that SNAP reform is a necessary component to the nationwide plan of reducing obesity, there are other key areas that need to be brought to attention alongside those mentioned already. Focusing on changing the built environment in areas densely populated by SNAP participants could also improve dietary habits and reduce the fast-growing obesity epidemic. The government is currently investing $400 million to bring supermarkets to

Chicuén 12 underserved communities, encouraging convenience shops to offer healthier options, and increasing the availability of farmers markets that accept SNAP benefits. Aside from improving the built environment in low-income communities, more research needs to be done on the efficacy of educational campaigns and technology-based interventions. SNAP-Ed, the largest nutrition education initiative in the country, offers $400 million annually in matching grants to states with the hope of enticing them to promote healthier diets among low-income consumers. Yet, when organizations tried to use these grants to discourage users from purchasing SSBs, the USDA stopped their efforts, which highlights how intertwined the USDA is with junk food companies. The obesity epidemic in the United States is increasing rapidly. Low-income communities that rely on SNAP benefits to purchase food are more likely to become overweight or obese than non-SNAP recipients. Although none of the articles analyzed in this reviewed were able to provide a causal relationship between SNAP participation and obesity, there is sufficient observational data to present to the USDA to fuel legislative change. This review is instrumental to the process of gathering support to meet the nutritional needs of SNAP beneficiaries and reduce the avenues leading to unhealthy food choices that stimulate weight gain and other health risks. If more research is done to prove that SNAP is contributing to obesity across the country, then perhaps the USDA will move rapidly to change these existing flaws. In any case, unhealthy food choices are weighing down the nation; it is up to the government and health officials to come together to tackle this growing issue while the resources are still available. SNAP has the potential to reduce obesity if the USDA willingly accepts the reforms put forth by researchers and health officials. By coming together, these individuals and agencies will have tools necessary to stop the pervasiveness of obesity in the United States.

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Works Cited Alston, Julian M., Conner C. Mullally, Daniel A. Sumner, Marilyn Townsend, and Stephen A. Vosti. "Likely Effects On Obesity From Proposed Changes To The US Food Stamp Program." Food Policy 34 (2008): 176-84. Print. Basu, S., Seligman, H., Gardner, C., & Bhattacharya,J. (2014). "Ending SNAP Subsidies For Sugar-Sweetened Beverages Could Reduce Obesity And Type 2 Diabetes." Health Affairs 33.6 (2014). Print. Economic Costs. (2012, October 20). Retrieved March 5, 2015, from http://www.hsph.harvard.edu/obesity-prevention-source/obesity-consequences/economic/ Hilmers, A., Chen, T., Dave, J., Thompson, D., & Cullen, K. (2014). Supplemental Nutrition Assistance Program participation did not help low income Hispanic women in Texas meet the dietary guidelines. Preventive Medicine, 62, 44-48. Kupillas, L., & Nies, M. (2007). Obesity And Poverty: Are Food Stamps To Blame? Home Health Care Management & Practice, 20(1), 41-49. Leung, C., & Villamor, E. (2010). Is participation in food and income assistance programmes associated with obesity in California adults? Results from a state-wide survey. Public Health Nutrition, 645-652. Leung, C., Willett, W., & Ding, E. (2011). Low-income Supplemental Nutrition Assistance Program participation is related to adiposity and metabolic risk factors. American Journal of Clinical Nutrition, 17-24. Levi, J., Segal, L., Laurent, R., & Rayburn, J. (2014, September 1). The State of Obesity: Better Policies for a Healthier America 2014. Retrieved March 3, 2015.

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Long, M., Leung, C., Cheung, L., Blumenthal, S., & Willett, W. (2014). Public support for policies to improve the nutritional impact of the Supplemental Nutrition Assistance Program (SNAP). Public Health Nutrition, 17(1), 219-224. Payne, G., Wethington, H., Olsho, L., Jernigan, J., Farris, R., & Walker, D. (2013). Implementing a Farmers’ Market Incentive Program: Perspectives on the New York City Health Bucks Program. Preventing Chronic Disease, 10.