Role of Supplemental Nutrition Assistance Program in Improving Diet Quality: Implications for Nurses

Abstract

The Supplemental Nutrition Assistance Program (SNAP) provides access to healthy food for low-income individuals and households. Food security, however, does not necessarily achieve higher diet quality for beneficiaries. Diet quality is an important consideration for the development and management of chronic illness, a significant public health concern. In this study, we review incentives and disincentives implemented to improve the diet quality, the evidence on SNAP including benefits, challenges, and the politics of funding. New interventions and policies will be needed in order to improve the overall diet quality of SNAP households. SNAP should align with nutritional science to meet national public health goals. Nurses are trusted advocates for patients and the public and are uniquely positioned to aid in this effort. Informed by evidence, nurses willing to leverage their influence, can lead this needed change.

Keywords

food stamps Supplemental Nutrition Assistance Program diet quality nutrition policy politics

Chronic disease is tied to a multitude of risk factors, including poor diet quality (Bauer et al., 2014). Diet quality is generally poorer at lower income levels (Hiza et al., 2013). Health care professionals, therefore, have a responsibility to understand the efficacy of programs such as the Supplemental Nutrition Assistance Program (SNAP). This entitlement program is intended to end hunger and increase self-sufficiency for individuals and households lacking dependable access to nutritious food, ultimately benefiting public health. Nurses are key proponents for patient- and population-level health and are uniquely positioned to influence health policy. The purpose of this study is to apprise nurses of the SNAP program and associated interventions, describe implications for nursing care, and engage nurses in the interventions needed to improve the nutritional intake for patients and populations under their care.

Supplemental Nutrition Assistance Program

SNAP is a federally funded program that provides benefits to low-income households to assist in paying for food (U.S. Department of Agriculture [USDA], 2019). Population-level food assistance in the United States can be traced back to 1939 when the initial food stamp program was started to address both high rates of unemployment and food surpluses. The program has witnessed alternating expansion and growth along with significant cutbacks and decreases in enrollment throughout the decades, with the height of participation peaking in 2013. Since 1992, the program has also focused on healthy diet goals for recipients by implementing nutrition education campaigns (https://www.fns.usda.gov/snap/short-history-snap#1939). By providing supplemental assistance for the provision of food along with education campaigns to increase healthy food choices, the goals are to both reduce food insecurity and improve overall diet quality. An increase in food expenditures could improve diet quality (Mabli et al., 2010).

With low-income levels determining SNAP eligibility, many SNAP beneficiaries struggle with food insecurity. Households that are food insecure are classified as households where at least one member reports reduced quality, variety, or desirability of diet and one or more members report indications of multiple disrupted eating patterns and reduced food intake (Gundersen & Ziliak, 2015). Food insecurity has thus been associated with poor diet quality and less intake of nutrient-rich foods such as fruits, vegetables, whole grains, and low-fat dairy (Hanson & Connor, 2014).

The USDA measures food insecurity by responses to the Food Security Supplement of the Census Bureau’s Current Population Survey (Heflin & Olson, 2017). For those participating in SNAP for 6 or more months, the program appears to decrease food insecurity by 5 to 10 percentage points (Mabli et al., 2013). Participation varies widely from state to state, but overall participation in SNAP is steadily decreasing nationwide (Greenstein et al., 2018). Participation peaked toward the end of 2012; however, the number of people enrolled in SNAP has fallen by more than 8 million since then, with a 12% decrease between 2013 and 2017 (Greenstein et al., 2018).

Benefits and Challenges of SNAP

Benefits

There are numerous individual- and population-level benefits of SNAP participation. Participating in SNAP for at least 6 months can reduce food insecurity by 5% to 10% (Mabli et al., 2013). Along with helping to reduce food insecurity, SNAP benefits for expectant mothers can reduce incidence of low-weight babies between 5% and 12% (Almond et al., 2011). Receiving SNAP benefits as a child can increase the likelihood of high school completion by 18% (Hoynes et al.,2016). SNAP is also associated with lower health care expenditures by low-income adults (Berkowitz et al., 2017). Furthermore, seniors who participate in the SNAP program are much less likely to be admitted to nursing homes and hospitals (Szanton et al., 2017).

Challenges

In addition to the numerous benefits, there are also challenges with the SNAP program. SNAP participation has been associated with the purchase of less healthy foods when compared with income-eligible nonparticipants (Pomeranz & Chriqui, 2015). Participants can purchase any food or beverage except for prepared foods, alcohol, and dietary supplements (Pomeranz & Chriqui, 2015). Before its implementation, although there was a proposal to include diet restrictions (such as no soft drinks or luxury foods), these limitations were not incorporated even after the reauthorization of SNAP in 2008 (Pomeranz & Chriqui, 2015). Andreyeva et al. (2012) evaluated sugar-sweetened beverages (SSBs) purchased by SNAP participants. While SNAP reduces food insecurity in terms of caloric and macronutrient and micronutrient intake, SNAP participants still struggle to meet key dietary guidelines than eligible and higher income nonparticipants (Andreyeva et al., 2015). Furthermore, evidence shows that SNAP recipients have worse diet quality than income-eligible nonparticipants (Nguyen et al., 2014; Zhang et al., 2018). Specifically, SNAP participants consumed fewer whole grains, fruits, vegetables, nuts, seeds and legumes, and more processed meat, high-fat dairy, and SSBs than income-eligible nonparticipants and higher income individuals (Andreyeva et al., 2015; Zhang et al., 2018).

A report published by the USDA in 2016 compared the types of food items purchased by SNAP and non-SNAP households. They suggest similar spending habits between the two groups, with SNAP households purchasing slightly more sweetened beverages (Garasky et al.,2016). However, non-SNAP households were not defined as income eligible for SNAP. Inclusion of higher income, non-SNAP-eligible households and a number of outstanding confounders likely influence these results and limit understanding of how SNAP affects dietary behaviors. This example illustrates the difficulty of analyzing the impact of SNAP on individual’s nutrition and dietary choices (Bitler, 2014). Even when income-eligible individuals are used as a comparison group for SNAP recipients, there may still be underlying differences between the two groups as SNAP is a voluntary program that one must opt into. For example, Zhang et al. (2018) reported that compared with income-eligible non-SNAP individuals, those participating in SNAP were younger, less likely to be non-Hispanic White, and more likely to be female. Utilizing data from the National Health and Nutrition Examination Survey from 1999 to 2014, SNAP participants experienced less improvement in American Heart Association diet scores and higher consumption of processed meats and added sugars than both income-eligible non-SNAP individuals and higher income individuals (Zhang et al., 2018). Given underlying differences between these groups, it remains unclear as to what determines the differences in diet between SNAP participants and income eligible nonparticipants; these may be the result of other factors beyond SNAP participation versus nonparticipation.

SNAP and Obesity

In the past, food insecurity has been associated with being underweight from having an inadequate quantity of food (Blumenthal et al., 2014). However, food insecurity is now more often associated with obesity, especially in women and children (Hernandez et al., 2017; Kaur et al., 2015). Participation in SNAP and other similar programs may be contributing in some ways to the rise of obesity in those that are food insecure (DeBono et al., 2012). However, the literature on SNAP and obesity remains largely inconclusive. A cross-sectional study by Zagorsky and Smith (2009) showed that participation in Food Stamp Program (FSP) (SNAP) led to an increase in body mass index (BMI) by 1 kg/m² in women, in contrast to nonparticipants of the same socioeconomic characteristics. A survey study conducted by Webb et al. (2008) demonstrated that participation in FSP (SNAP) or in any federal nutrition program 12 months prior to the study was associated with an increased BMI of 3 kg/m² in adults. Another cross-sectional study by Leung and Villamor (2011) showed that the prevalence of obesity was 30% higher in SNAP participants in contrast to nonparticipants. A study conducted by Meyerhoefer and Pylypchuk’s (2008) showed that program participation by women led to a 5.9% increase in their likelihood of obesity, a much lower number than previous estimates. Recent work by Ridgon et al. (2017) showed the correlation between SNAP participation and BMI and noted little to no causal relationship between SNAP and obesity noting likely confounding by unmeasured covariates. A study by Almada and Tchernis (2018) showed that increases in SNAP benefits have no effect on obesity levels. The association between obesity and SNAP remains largely inconclusive and there is a need to clarify this relationship with future well designed robust studies.

Foods Purchased and Diet Quality of SNAP Participants

The types of foods purchased, and the overall diet quality of SNAP participants is of concern. Interestingly, the USDA found that SNAP and non-SNAP participants make similar food purchases in 2011 point of sale data. For both SNAP and non-SNAP participants, 40 cents of every dollar for food expenditures were spent on basic items like milk, bread, meat, eggs, fruits, and vegetables, 20 cents was spent on sweetened drinks, desserts, candy, sugar, and salty snacks, and the remaining 40 cents were spent on a variety of other items. Both SNAP and non-SNAP participants spent more money on soft drinks than any other item, although SNAP participants spent 1% more on them (Garasky et al., 2016). Moreover, SNAP participants obtained more calories from empty calories than either income-eligible nonparticipants or higher income individuals but on average consumed less calories per day than the other two groups (Garasky et al.,2016). SNAP participants were also less likely to consume fruits and vegetables (FV) and more likely to be obese than either income-eligible nonparticipants or higher income individuals. More recently, studies such as Pomeranz and Chriqui (2015) and Zhang et al. (2018) demonstrated that SNAP participation is associated with the purchase of less healthy foods when compared with income-eligible nonparticipants. Zhang et al. (2018) showed that SNAP participants had less improvement in their American Heart Association (AHA) diet scores in contrast to both income-eligible nonparticipants and higher income individuals. Overall, the diet quality measured by the Healthy Eating Index-2005 was lower in SNAP participants who had a total score of 56.8 in contrast to both income‐eligible nonparticipants and higher income nonparticipants who had Healthy Eating Index scores of 60.3 and 60.2, respectively (Condon et al.,2016). Although diet quality is poor for SNAP participants, the SNAP education program has demonstrated success in increasing consumption of FV, instilling a positive attitude for healthy eating, increasing consumption of low-fat and nonfat milk in place of whole milk, and decreasing consumption of soft drinks (Condon et al.,2016; V. Long, 2013). V. Long (2013) evaluated the outcomes of the Eat Smart, Live Strong program which included SNAP participants and found that Eat Smart, Live Strong participants ate more FV (2.97 cups) in contrast to the comparison group (2.65 cups) after a follow-up. Furthermore, studies have found that SNAP participants make healthier food choices when given a financial incentive such as a coupon for healthy foods, and when exposed to targeted merchandizing including product placement, and promotion strategies to raise the profile of healthier foods (Gordon et al., 2014). This becomes especially pertinent for nurses to be aware of with the increasing rates of obesity and the severity of chronic illness care, which all have been previously linked to poor dietary choices (Laraia, 2013; Steven & Brynne, 2018; World Health Organization, 2003).

Proposed Improvements for SNAP

Removing SSBs

SNAP participants are currently able to purchase any food or beverage item (excluding alcohol) with their benefits. In SNAP households, it is estimated that 58% of beverage purchases are sugar-sweetened and the SNAP benefits paid for about 72% of the sugar-sweetened drinks (Andreyeva et al., 2012). SSBs have been significantly associated with weight gain, increased risk of type 2 diabetes, and cardiovascular disease (Malik et al., 2010). To improve the dietary quality of SNAP participants, it would be important to limit or remove benefits for SSBs. Approximately 54% of SNAP participants support removing benefits for SSBs, and around 70% of the general public support removing them (Blumenthal et al., 2014). The estimated health benefits of removing SSBs are enormous, with estimated reduction in heart attacks, diabetes, and stroke (Basu et al., 2013). The exclusion of these beverages would be an effective method to achieve better health and diet of low-income food insecure individuals. However, there are ethical objections to this due to equity issues of excluding sweetened beverages from SNAP. For instance, a study by Barnhill (2018) showed that excluding sweetened beverages reduces the consumer choice of SNAP participants which creates a disparity in consumer choice.

Incentives for Healthy Food Purchases

A 2014 study of 3,024 adults found that 82% of respondents supported providing additional benefits to program participants for the purchase of healthy foods (M. W. Long et al., 2014). Low use of incentive programs may be an issue. Several studies have explored the use of additional benefits, or incentives, to increase the purchase of healthy foods in an effort to improve the SNAP diet quality (Baronberg et al., 2013; Choi et al., 2017; Harnack et al.,2016; Leung et al., 2017; Olsho et al., 2017). The Healthy Incentives Pilot (HIP) provided incentives to SNAP participants to purchase FV in a county in Massachusetts. In this study, HIP participants bought and ate more FV and of greater variety when compared with non-HIP participants. The participants also reported that FV were more affordable. Ninety percent of retailers found HIP easy to operate (USDA, Food and Nutrition Service, 2014). Another study examined the Double-Up Food Bucks (DUFB) waiting room intervention in Michigan. DUFB matches the amount of SNAP funds spent at farmer’s markets. At baseline, findings showed that 57% of participants reported shopping at a farmer’s market. Follow-up measures at the end of the program illustrated a significant increase in DUFB use, with 69% of participants reporting use of DUFB at least once, and 34% reporting use of DUFB 3 or more times. The consumption of FV also significantly increased from baseline (Cohen et al., 2017). The government thus has the ability to implement incentives like HIP and DUFB, aligning SNAP with nutrition science and national public health goals (Pomeranz & Chriqui, 2015). In addition, Baronberg et al. (2013) investigated the impact of the New York City’s Health Bucks Program—which provides a $2 coupon for every $5 spent using SNAP—on the use of SNAP benefits at farmers markets by analyzing 4 years of electronic benefit transfer (EBT) sales data. Their findings showed increased average EBT sales in farmers markets with the incentive in contrast to those without the incentive. Another study by Choi et al. (2017) exploring the cost-effectiveness of subsidizing a diet high in FV in SNAP participants illustrated that nationwide FV incentives would decrease mortality, chronic disease morbidity, and costs over long-term periods. A similar study by Harnack et al. (2016) examined the incentivization of FV and the prohibition of less nutritious foods in a food benefit program. Their results suggested that FV incentives paired with restricted purchases may decrease energy intake and improve diet quality compared with programs that do not include incentives or restrictions.

On a national scale, successful strategies used by other states can be adopted or adapted. For instance, the Georgia Fresh for Less Program administered by Wholesome Wave Georgia, double-matches SNAP/EBT benefits to promote fresh, local food purchases at participating farmers’ markets for SNAP beneficiaries (https://www.wholesomewavegeorgia.org/georgia-fresh-for-less/). A 2016 Wholesome Wave Georgia Customer Survey shows that Georgia Fresh for Less aided 80% of shoppers to increase their daily servings of fresh fruits and vegetables. In Alabama, the purchase of nutrient dense foods (fruits, vegetables, and low-fat dairy) increased after an intervention with education and a coupon discount for a specified list of healthy foods than after intervention with only education or no intervention at all (Jun et al., 2018). These studies illustrate that an increase in SNAP benefits can lead to modest improvements in nutrition and diet quality.

Another important strategy is to incentivize the amount of money SNAP participants can spend on healthier food options. Although the base value of SNAP benefits is fixed across all states in the United States (except for Hawaii and Alaska), food prices vary greatly across the country (Christensen & Bronchetti, 2017). A recent study by Christensen and Bronchetti (2017) investigated the variation in the purchasing power of SNAP and evaluated whether SNAP benefits are adequate to purchase the Thrifty Food Plan, a USDA food plan representing a nutritious diet at a low cost. Their results showed that SNAP benefits (plus 30% of net income) are inadequate for 20% to 25% of households to purchase the Thrifty Food Plan. These households noted an average shortfall of approximately $150 per month. Another motivation to increase the amount of money SNAP participants can spend on food includes the cost of a healthier lifestyle. A systematic review conducted by Rao et al. (2013) evaluating 27 studies showed that healthier food choices have a much higher cost in contrast to less than healthy foods, with healthier diets costing $1.48/day and $1.54/2,000 kcal more than less healthy options. During the last several decades, the cost of fruits has increased by approximately 200%, while the price of sugar has only increased by 30% (Finkelstein & Zuckerman, 2010). This in conjunction with the success of programs such as the HIP study—which showed that giving a 30 cent credit for every SNAP dollar spent on FV increased purchases of those items by 26% (Bartlett & Abt Associates, 2014)—which prompts for a call of action by nurses to improve the SNAP spending and improve the diet quality.

Politics of SNAP and Stakeholders

The 2018 Farm Bill passed the House and Senate without the substantial budget cuts and without the stricter work requirements(Parks et al., 2019). Under the 2018 Farm Bill, there was a slight increase and expansion of the SNAP Employment and Training program and an expansion and mandatory funding of the Gus Schumacher Nutrition Incentive Program along with an elimination of the state performance bonuses (Food Research and Action Center, 2018). However, there is a push from the current administration for the USDA to pursue a “SNAP Rule” that will put the stricter work requirements into SNAP and thus decrease SNAP expenses (USDA, Food and Nutrition Service, 2018).

Many individuals and organizations are affected by SNAP and the funding of SNAP. The largest group of stakeholders are the low-income and unemployed individuals and their children who rely on SNAP. State government officials are policy stakeholders as many of the specifics of SNAP are up to the individual states. States also rely on the federal government to provide them with the necessary funds to run and monitor SNAP programs. Public health department officials and directors of obesity prevention programs have a stake as SNAP affects both nutrition and diet-related health outcomes. Other policy stakeholders include leaders of antihunger, agriculture policy, and advocacy organizations who push for increasing food assistance, farmers, and representatives of food manufacturing companies, grocery and convenience stores who provide the food for the SNAP recipients (Blumenthal et al., 2014).

As research indicates that SNAP recipients may have worse dietary quality than income-eligible nonparticipants, policy makers have urged the USDA (USDA, Food and Nutrition Service) to pilot SNAP purchasing restrictions to support a healthier diet, and state legislators have proposed similar bills (Pomeranz & Chriqui, 2015). Despite this, USDA has rejected invitations to date, stating it is administratively and logistically difficult to differentiate products (Pomeranz & Chriqui, 2015). This position contradicts what the USDA already does for the Supplemental Nutrition Program for Women, Infants, and Children (Pomeranz & Chriqui, 2015).

The current law allows households that qualify for Temporary Assistance for Needy Families Programs in states with broad-base categorical eligibility policies to avoid having to meet federal income and can receive SNAP benefits. Recently, research analyzed state-level impacts of the USDA proposal to end SNAP broad-base categorical eligibility. The proposed rule from the USDA would eliminate the SNAP program in 39 states. This analysis determined that 1 in 10 SNAP households nationwide-equal to 3.6 million in the 2016 SNAP caseload will lose eligibility under this proposed rule (“Impact of Proposed Policy Changes,” 2019).

Implications for Nurses

Nurses have a professional obligation to promote health equity and assess for the social determinants of health, whether working at the individual patient or population level of care. SNAP is a broad reaching program with the potential to make inroads related to income inequality and disparate health outcomes. Nurses can address the current evidence gaps, gain political savvy to increase advocacy reach, and incorporate knowledge of the relationship between dietary quality and overall health into individual clinical practice.

Nurses have a unique ability to add to the evidence base by conducting needed studies. Larger scale and more robust research led by nurses can help us understand the health outcomes of SNAP participants with varying levels of dietary quality, the effectiveness of using incentives for healthier food purchases, and the impact of SNAP participation on obesity rates or other diet-related health outcomes. Prospective long-term studies examining SNAP eligible patients and their health outcomes compared with non-SNAP participants are needed. More detailed information on what foods SNAP participants are purchasing along with what influences participants purchasing decisions will be important.

Advocacy is another critical role for nursing. This charge requires nurses to be knowledgeable of the current evidence and the contemporary issues facing the politics and funding for SNAP or like programs. Armed with this, nurses can rally colleagues and connect to professional associations, write letters to legislators, and use their individual and professional social platforms to raise awareness. Informed nurses can help dispel misunderstandings and lobby for more and better spending on SNAP in order to improve the nutrition. Improved nutrition will ultimately decrease the burden of chronic disease in our nation.

At present, our nursing workforce is challenged by the complexity of chronic illness care, much of which has been associated with poor nutrition and increasing obesity rates (Laraia, 2013; Steven & Brynne, 2018). Direct care nurses are just as essential to improving health equity. These are the nurses with ideas for innovative interventions and can take responsibility for more successful uptake of proposed changes. Nurses are considered unique within the health care profession because of their increased presence with patients. Often, nurses gain an intimate understanding of their patients’ motivations, their unique context, and their individual capacity for improved health. All health care professionals will need to work together to educate and support behavior change for low-resource individuals. This also means collaborating at both the bedside and the community level to promote and sustain large scale change.

Increasing SNAP funding overall would allow for more effective methods to increase participant spending on more nutrient-dense food in order to improve the diet quality and population health. Decreased inequities such as food insecurity in public health can potentially reduce health care costs (Pruitt et al., 2018). It is important to understand the administration of programs like SNAP and its’ intended benefits. Nurses have a great opportunity to lead and operationalize change, and armed with this knowledge can help to raise the level of nutrition among low-income households.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Center for Scientific Review (5R00NR014675-06)

Author Biographies

Victoria M. Pak, PhD, RN, MS, MTR Assistant Professor at the Emory University Nell Hodgson Woodruff School of Nursing. Her research is focused on understanding the mechanisms of symptoms and chronic disease with expertise in sleep and cardiovascular research.

Erin Ferranti, PhD, MPH, RN, CDCES, FAHA Assistant Professor at the Emory University Nell Hodgson Woodruff School of Nursing whose research is focused on identifying the role of the gut microbiome and effective dietary strategies to mitigate cardiometabolic risk burden in women of childbearing age who have had cardiometabolic complications during pregnancy.

Ingrid Duva, PhD, MSN, RN Senior Clinical Instructor at the Emory University Nell Hodgson Woodruff School of Nursing interested in health services research. Her clinical experience is in pediatrics; cardiac, peri-operative services, community and primary care.

Melissa Owen, PhD, RN, CNE, FHFSA Assistant Clinical Professor at the Emory University Nell Hodgson Woodruff School of Nursing. Her research areas of interest include understanding palliative care incorporation within the experience of heart transplant candidates and recipients.

Sandra B. Dunbar, RN, PhD, FAAN, FAHA, FPCNA Charles Howard Candler Professor and Senior Associate Dean for Academic Advancement at Emory University Nell Hodgson Woodruff School of Nursing. She has a long history of studying cardiovascular populations and improving outcomes through tests of clinical interventions.

ORCID iD

Victoria M. Pak

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