CC BY-NC-ND
0american journal of
Preventive Medicine
|specialarticle|
Behavioral Economics and the Supplemental Nutrition
Assistance Program: Making the Healthy Choice the Easy Choice
Alice S. Ammerman, DrPH,1,2 Terry Hartman, MPH, MS, CCRC,3 Molly M. DeMarco, PhD1,2
The Supplemental Nutrition Assistance Program (SNAP) serves as an important nutritional safety net program for many Americans. Given its aim to use traditional economic levers to provide access to food, the SNAP program includes minimal nutritional requirements and restrictions. As food choices are influenced by more than just economic constraints, behavioral economics may offer insights and tools for altering food purchases for SNAP users. This manuscript outlines behavioral economics strategies that have potential to encourage healthier food choices within the SNAP program. Am J Prev Med 2017;52(2S2):S145-S150. © 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4M/).
INTRODUCTION
The Supplemental Nutrition Assistance Program (SNAP) in various iterations has provided critical support to food-insecure individuals for more than 75 years. It has served as an important food safety net program, as evidenced by participation rates increasing substantially after the 2008 economic downturn.1 A recent White House report showed that SNAP has played an essential role in lifting families out of poverty and hunger.2 However, the impact on diet quality has been more modest, and it is evident that SNAP participants, like most Americans, have substantial room for improvement in the dietary factors most associated with chronic disease risk.3,4 The SNAP program is designed around traditional economic levers, such as income supplementation, but this alone does not appear adequate to promote healthy choices. Behavioral economics offers a collection of theories and strategies5,6 that, when implemented, can change the environment to "make the healthy choice the easy choice" by nudging individuals toward healthier food selection in retail and other food choice situations.
Since the first iteration of SNAP (formerly Food Stamps) was implemented in 1939, nutrition-related health challenges have changed markedly. The program was initially designed to address protein/calorie insufficiency and also had a role in reducing agricultural surpluses.7 The U.S. now faces a food insecurity-obesity paradox, where many individuals suffer from both
conditions simultaneously.8 The problem is now more commonly one of not "knowing where the next meal is coming from" or lack of access to affordable, healthy food, rather than calorie deficits. Low-income individuals are likely able to obtain enough calories but these calories may come from cheap foods that are calorie dense and nutritionally poor. Therefore, nutrition and health professionals now increasingly use the term food insecurity, an economic concept, rather than the biological notion of "hunger."9 Though national survey data show that SNAP participants value nutrition, their time and financial constraints complicate the task of making healthy food choices.10 To address this issue, the U.S. Department of Agriculture (USDA) has developed the Thrifty Food
From the department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; 2Center for Health Promotion and Disease Prevention (CDC Prevention Research Center), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and 3Sanford School of Public Policy, Duke-UNC USDA Center for Behavioral Economics and Healthy Food Choice Research, Duke University, Durham, North Carolina
Address correspondence to: Alice S. Ammerman, DrPH, Center for Health Promotion and Disease Prevention; Department of Nutrition, Gillings School of Global Public Health and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill NC 27599. E-mail: alice_ammerman@unc.edu.
This article is part of a supplement issue titled The Supplemental Nutrition Assistance Program's Role in Addressing Nutrition-Related Health Issues.
0749-3797/$36.00
http://dx.doi.org/10.1016Aj.amepre.2016.08.017
© 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. Am J Prev Med 2017;52(2S2):S145-S150 S145
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Plan, which promotes affordable recommendations to follow the Dietary Guidelines for Americans predicated on the fact that people are primarily cooking at home.11'12 Though potentially lacking adequate refrigeration, meal preparation facilities, or transportation, some SNAP and other low-income families may have to rely heavily on non-perishable processed calorie-dense foods to help stretch SNAP benefits to the end of the month.10,13
The SNAP program provides the potential for many families to purchase healthier food. Other USDA nutrition assistance programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are restricted to "healthier" foods consistent with the Dietary Guidelines for Americans. However, SNAP has very few restrictions on the type of foods that can be purchased, giving the consumer more flexibility and freedom of choice. With flexibility comes the potential to make either healthy or less healthy choices. The SNAP-Ed (education) program, also funded by the USDA, represents the most far-reaching nutrition education program available for low-income consumers. SNAP-Ed is funded at a level of more than $400 million annually and seeks to reach 95 million Americans with incomes below 185% of the Federal Poverty Level.14 It is designed to help low-income individuals, including those on SNAP, make healthful food and physical activity choices. The SNAP-Ed Toolkit15 includes a list of SNAP-Ed interventions that have been reviewed and deemed evidence based for broader dissemination. In 2010, the SNAP-Ed program added obesity prevention, along with nutrition education, to its mandate and embraced changes to the policies, systems, and environments that facilitate better food choices by low-income consumers. Behavioral economic theory is being incorporated into interventions in traditional (supermarkets and convenience stores) and non-traditional (farmers' markets and food co-ops) retail environments to nudge consumers toward healthier food choices.16-18 These interventions can be used to nudge SNAP recipients and other low-income consumers through the SNAP-Ed program.
Behavioral economics has been popularized by books such as Nudge5 and Switch.19 The subtitle to Nudge is "Improving Decisions About Health, Wealth, and Happiness," whereas for Switch it is "How to Change Things When Change Is Hard." Together, these phrases capture the challenges faced by SNAP recipients, who have limited resources and time, making healthy food choices that much harder. Behavioral "nudges" are a key component of behavioral economics. As defined by the authors of Nudge, Thaler and Sunstein,5 "A nudge is any aspect of the choice architecture that alters behavior in a predictable way without forbidding any options or significantly changing their economic incentives." Behavioral nudges and food psychology in combination with more-traditional
economic levers such as price, income supports, and information are creating opportunities to foster healthier food intake among SNAP recipients.
In a review for the Economic Research Service of USDA, Just and colleagues20 addressed the question "Could behavioral economics help improve diet quality for nutrition assistance program participants?" In recognizing that food choices are determined by factors beyond traditional economic forces, Just suggests that behavioral economics can "illuminate a broad array of strategies to influence consumers' food choices." In doing so, behavioral economics expands the list of possible strategies for improving the diet quality and health of participants in USDA nutrition assistance programs such as SNAP.
BEHAVIORAL ECONOMICS AND HEALTH PSYCHOLOGY TRIGGERS
Behavioral economics triggers that can lead to either healthy or unhealthy food choices can help to identify potential areas for nudging SNAP recipients toward healthier choices. Many of these approaches overlap or work best in coordination.
Choice Architecture
Choice architecture refers to an approach to influencing consumer decision making through the design of environments in which choices are made. Consumers often describe "willpower" as the missing factor that prevents them from making and maintaining healthy dietary change. This construct relates to the ability to resist temptation and make the behavioral decisions and actions required to stick to a plan for improved nutrition. However, the current food environment creates temptations and messages encouraging less healthy food choices; willpower is easily overwhelmed. Choice architecture can be used to create environments where healthy choices are more obvious and easier to make, requiring much less in the way of self-control or willpower. An example of how choice architecture can be used with the SNAP population is through product placement within the retail setting. Healthier food items can be placed on end caps, at eye level, or near the checkout aisles. Another approach to choice architecture involves default options— pre-set courses of action that transpire without any decision making required of the consumer. One default option may be to couple the new provision of the recent farm bill that allows the purchase and delivery of foods to homebound elderly or disabled SNAP participants with limiting the selections of food available for purchase to healthier items.21
Cues are important environmental triggers that can either tempt one into making bad decisions or remind
the consumer that they are trying to make healthy changes. Cues and environmental triggers are used extensively in the Smarter Lunchroom intervention developed and tested at the USDA-funded Cornell Center for Behavioral Economics in Child Nutrition.22 Those implementing Smarter Lunchrooms place fresh fruit in an appealing, well-lit bowl. They might also place chocolate milk behind the healthier dairy options so it is less visible and harder to reach. Potential cues for SNAP participants may include placing healthy, economical food items in prominent locations, including checkout, improving lighting at displays of healthier options, or creating visually appealing displays within grocery retail outlets frequented by SNAP shoppers to promote their sale. Although there is evidence that these cues work in the short run, it is less clear whether they continue to nudge behavior change after the novelty has worn off.
Present Bias/Hyperbolic Discounting
Present bias/hyperbolic discounting refers to the tendency for people to choose a smaller/sooner reward over a larger/later reward, and thus greater emphasis on the present and on pleasurable inputs, at the expense of considering future implications such as adverse health outcomes associated with poor dietary choices. Although not unique relative to other shoppers, this is an understandable problem facing a low-income SNAP shopper with a young child or two riding in his shopping cart. Pleasing an irritable child can easily trump choosing the healthiest options. To combat the desire to choose a smaller/sooner reward and save SNAP funds for other purchases, grocery outlets could provide healthy snacks to children as they are shopping with their parents. In fact, recently some supermarket retailers have begun offering a complementary piece of fresh fruit to children while shopping with an adult. Not only does this send a message that the retailer cares about customer well-being (by offering a healthy option as opposed to the frequently offered free cookies), it may be an effective business strategy to increase customer purchases of that fruit if the child decides he or she likes it, thus serving as a behavioral cue as well.
Cognitive Overload
Cognitive overload can impair decision making owing to the complexity or volume of information, such as reading and interpreting food labels or determining the unit cost of a product. This can be a significant problem in a typical grocery store that stocks up to 42,000 different items. Creative approaches have shown promise in retail establishments, using simple cues such as arrows on the floor pointing toward the produce section or grocery basket signs encouraging greater selection of fresh
produce.23 Other strategies include bundling of healthier food options such as salad ingredients or vegetable stir fry. Bundling is often used by retailers to increase sales or move perishable products. This could mean a win-win between SNAP customers and grocers because bundling of produce in set dollar amounts can facilitate purchase by SNAP customers needing to stay within their SNAP allotment. Budgeting is easier when the cost of a set amount of produce is known versus finding out when weighed at the time of checkout.
Salience
Salience pertains to the availability of necessary information at the point of decision. For example, WIC participants often find it difficult to identify WIC-approved foods when not clearly labeled. "Shelf talkers" and grouping healthier options on aisle end caps use behavioral economics strategies to put healthier options in front of customers and make their purchase easier. End caps change frequently to market different products as they depend on the salience of change to get the consumer's attention. Most studies of end caps and healthier food choices are based on short-term trials. More research is needed to determine the willingness of retailers to maintain healthier end caps and whether nudges toward healthy choices have a persistent impact over time. The aforementioned bundling example may be another way to use salience to nudge SNAP customers toward healthy choices because the necessary information (exact produce price) is provided.
Pre-commitment
Pre-commitment involves making choices or partial decisions prior to entering a more tempting environment, at a time when one can be more thoughtful about the challenges of "present bias." A simple example is using a shopping list and sticking to it. Pre-commitment also offers a number of interesting opportunities within the SNAP program. As mentioned above, the most recent farm bill permits food ordering and delivery programs to become authorized SNAP retailers if they meet SNAP requirements and serve elderly and disabled SNAP recipients who are unable to come to a retail location to shop for food.21 Placing an order from home while not tempted by the many options in a grocery store and perhaps using SNAP-Ed tools that nudge toward healthier choices may lead to better diet quality. In another development, SNAP recipients are now able to use their benefits to pay for "shares" in a Community Supported Agriculture program. Members generally buy a "share" in a local farm at the beginning of the season and then receive a box of seasonal fresh produce each week. Non-profit and for-profit farmers' markets and direct
marketing farmers that operate a Community Supported Agriculture model can accept payment up to 14 days in advance of delivering the food to the SNAP customer or making the food available for pickup. This is a form of pre-commitment, as those SNAP funds are "committed" to fresh farm produce and thus not available to purchase less healthy items from traditional retailers.
Loss/Risk Aversion
Loss/risk aversion refers to people's tendency to strongly prefer avoiding immediate losses over acquiring longer-term gains. A recent study suggests that low-income primary caregivers choose to minimize the cost of uneaten and thus wasted foods by choosing to purchase more calorie-dense, processed foods they know their children will eat. Higher-income caregivers, who have the resources to withstand the cost of uneaten food, are more likely to repeatedly introduce healthier food items that their children might reject at first but learn to like over time.24 It is easy to see how the loss/risk aversion among lower-resource caregivers like SNAP recipients could impact their children's taste acquisition and longer-term eating habits.24 This suggests the need for new food introduction and taste testing in schools and other settings where the cost associated with early refusals is not absorbed by the consumer. Strategies to make it easy to let parents know when children try and like a healthy food while at school or in child care could also increase the SNAP caregiver's willingness to try serving the food at home. The aforementioned idea of a healthy snack provided to a child while shopping with the parent is another way to address risk aversion among SNAP recipients as their child gets to try a new food item with no monetary risk to the parent.
BEHAVIORAL ECONOMICS AND SNAP POLICY
There are a number of ways in which SNAP Policy at the national or state level can build on or facilitate behavioral economics approaches to further enhance healthy food choices.25
More-Frequent SNAP Benefit Issuances
Some SNAP advocates have proposed the idea to break the food stamp cycle of receiving all benefits at the beginning of the month and running out by the end of the month by spreading out benefits issuance over the month and avoiding lean times at the end of the month. Because SNAP participants are more likely to use the majority of their benefits when they first receive them instead of budgeting to last throughout the month,26 twice-monthly versus monthly payments could be useful to facilitate the
purchase of perishable products, such as fruits and vegetables, throughout the month. This is a change that could be made at the state level and has already been implemented in Michigan.27 However, even with spreading of benefits over time, without a healthier food environment, nutrition education, or behavioral nudges, the result could still be poor food choices. As described above, the SNAP-Ed program has identified evidence-based interventions in a toolkit for SNAP-Ed providers that could address this concern (toolkit),15 through educating consumers on stretching the food dollar or using SNAP to purchase and preserve seasonal bulk (and thus less expensive) produce from farmers markets or farm stands through canning or freezing. More research is needed to understand whether more-frequent food SNAP benefit issuance would result in better food choices.
Subsidizing Healthy Foods
Studies have shown that subsidizing the purchase of healthy foods can raise the consumption of these items. The 2008 Farm Bill authorized $20 million for pilot projects to determine if incentives provided to SNAP recipients at the point of sale increase the purchase of fruits, vegetables, or other healthful foods. This effort was referred to as the Healthy Incentives Pilot (HIP). Under HIP, SNAP participants received an incentive of 30 cents for every SNAP dollar spent on targeted fruits and vegetables credited back to their SNAP Electronic Benefit Transfer card. The incentive could then be spent on any SNAP-eligible foods and beverages. Study results show that HIP participants consumed 26% more targeted fruits and vegetables than non-HIP participants—about 0.25 cup more per day—and purchased a greater variety of fruits and vegetables.28 The Agriculture Act of 2014 (P.L. 113-79) authorized USDA to provide grant funds to eligible organizations to design and implement point of purchase incentive projects to increase fruit and vegetable purchases among SNAP participants. USDA is funding a number of projects through this Food Insecurity Nutrition Incentive Grant Program29 and is conducting an independent evaluation. This cost offset assistance is a more direct economic lever to purchasing more fruits and vegetables.
Retailers' Food Stocking Requirements
As required by the 2014 Farm Bill, USDA has proposed a rule designed to provide SNAP participants increased access to healthy foods by requiring stores that accept SNAP to stock a wider array of food choices. The stocking provisions in the proposed rule would require SNAP-authorized retail establishments to offer seven varieties of qualifying foods in four staple food groups for sale on a continuous basis, along with perishable
foods in at least three of the four staple food groups. The staple foods groups are dairy products; breads and cereals; meats, poultry, and fish; and fruits and vegetables. A focus of the proposed rule is to increase healthier food access in areas where consumers might depend on smaller grocery, convenience, and gas-mart retailers for an increasing volume of their food purchases in the absence of more-traditional and larger food retailers. Research regarding current stocking practices of non-traditional retailers suggests that implementing these rules may be challenging for smaller retailers. Assisting retailers to implement the new SNAP stocking requirements, including nudges to encourage purchases of the newly stocked items, represents a behavioral economics approach to adapting to new SNAP regulations.30 Nudging consumers toward purchases of fresh or frozen fruits and vegetables when they are not accustomed to buying these foods in a small convenience store has the potential to help retailers with stocking requirement implementation.
Pre-order and Home Delivery
As described above under pre-commitment strategies, new SNAP rules will allow consumers to order foods for delivery or to prepay with SNAP in certain situations. More work is needed to study the impact of these rule changes, but there is significant potential to overcome access barriers as well as create behavioral nudges toward healthier choices. In addition, such flexibility can help reduce the stigma associated with program participation.
Food Restrictions
Limiting foods allowed on the SNAP program could be described as a default option approach in behavioral economics. As described above, the WIC program uses this approach by providing food benefits but prescribing the specific foods that can be purchased. There is currently much debate about the strategy of restricting the type of foods that can be purchased on SNAP. Most often mentioned is removing sugar-sweetened beverages (SSBs) from eligible SNAP foods, given mounting evidence that SSBs are strongly associated with obesity and diabetes. Those opposing this idea have held that it is a paternalistic approach and that the primary benefit of SNAP is as an income supplement. Proponents, on the other hand, believe that the SSBs contribute only negatively to a healthy diet and that SNAP participants are often targeted by beverage advertising. Several articles in this journal supplement address the pros and cons of restricting SSBs on SNAP benefits.
Behavioral economics strategies and psychology could be useful in helping "win over" consumers to a policy that would remove SSBs from SNAP benefits. The food
industry has used the strategy of pre-commitment to support consumer desire for self-control or willpower. Almost half of Americans worry about their weight "all" or "some of the time." Fear of overconsumption of highly palatable foods has resulted in a substantial market for 100-calorie packs of snack foods. By purchasing these limited portion size packages, consumers are pre-committing that they will eat only what is in the package they purchased, as opposed to trying to limit their intake from a standard package of cookies. Although it is always possible to eat a second or third 100-calorie packet, the packs are perceived as an aid to weight control efforts for which consumers are willing to pay more. Interestingly, consumers revolted when the same strategy was proposed in New York City regarding SSB portion size, with consumers seeing it as an affront to free choice. Of course in this case, food companies were not benefiting from the sale of a smaller portion size. The Leung article31 in this issue presents an interesting opportunity in that it adds to the evidence that a majority of SNAP consumers approve of restricting SSB access on the program, particularly when paired with a healthy food incentive (SNAP+). Taking a page from the food industry 100-calorie snack package playbook, perhaps such a strategy could be "sold" to SNAP participants as a way to assist them with healthier choices for their family using behavioral economic strategies, incentivizing healthier choices, and removing the need for SSB self-control, thus making the healthy choice easier.
DISCUSSION AND CONCLUSIONS
The SNAP program serves as an important federal food safety net for many in the U.S. Given its aim to use traditional economic levers to improve access to food, the SNAP program includes minimal food restrictions. Food choice, however, is influenced by more than just economics. Consumers make complicated decisions about how to spend their food dollars every day. The behavioral economics strategies discussed here may offer useful tools to encourage healthier food choices within the SNAP program. This manuscript outlines behavioral economics strategies that have the potential to encourage healthier food choices by SNAP participants. However, more research is needed in this promising area to determine the impact and inform future policy directions.
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.
Funding for this study is provided by the Duke-UNC USDA Center for Behavioral Economics and Healthy Food Choice Research, which is funded by grant 59-5000-4-0062 from the U.S. Department of Agriculture. The authors express their sincerest gratitude to Dr. Joanne Guthrie, Dr. Anita Singh, and Barbara Murphy from the U.S. Department of Agriculture for their thoughtful review and comments in the development of this manuscript.
The views expressed in our research are those of the investigators and cannot be attributed to the U.S. Department of Agriculture, its Economic Research Service, or its Food and Nutrition Service.
No financial disclosures were reported by the authors of this paper.
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