Scholarly article on topic 'Moving Beyond the Debate Over Restricting Sugary Drinks in the Supplemental Nutrition Assistance Program'

Moving Beyond the Debate Over Restricting Sugary Drinks in the Supplemental Nutrition Assistance Program Academic research paper on "Health sciences"

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Abstract of research paper on Health sciences, author of scientific article — Marlene B. Schwartz

To address the dual problem of food insecurity and poor nutrition, the U.S. Department of Agriculture has recently revised the nutrition standards for nearly all of its federal food programs to align with the Dietary Guidelines for Americans. One notable exception is the Supplemental Nutrition Assistance Program (SNAP). Policy proposals to restrict SNAP benefits based on nutrition quality (e.g., excluding sugary drinks) have generated controversy and have polarized previous research and advocacy allies. This essay presents many of the issues that have emerged, which include challenges about the feasibility, justification, and effectiveness of restricting benefits; the risk of a slippery slope; concerns about participant dignity; and finally, distrust about the motives behind promoting and opposing a policy change. The purpose of this review is to increase mutual understanding and respect of different perspectives. The conclusion is that the rationales behind both support and opposition to updating the policies regulating SNAP benefits based on nutrition are fundamentally the same—the belief that a fair and just society cares for and protects vulnerable citizens, which in this case are low-income Americans who need assistance affording healthy food. Recommendations include activities to restore trust between the public health and anti-hunger communities, authentic engagement of SNAP participants in the conversation, and an optional SNAP program that includes both incentives and restrictions.

Academic research paper on topic "Moving Beyond the Debate Over Restricting Sugary Drinks in the Supplemental Nutrition Assistance Program"

AMERICAN JOURNAL OF

Preventive Medicine

|specialarticle|

Moving Beyond the Debate Over Restricting Sugary

CrossMaik

Drinks in the Supplemental Nutrition Assistance Program

Marlene B. Schwartz, PhD

To address the dual problem of food insecurity and poor nutrition, the U.S. Department of Agriculture has recently revised the nutrition standards for nearly all of its federal food programs to align with the Dietary Guidelines for Americans. One notable exception is the Supplemental Nutrition Assistance Program (SNAP). Policy proposals to restrict SNAP benefits based on nutrition quality (e.g., excluding sugary drinks) have generated controversy and have polarized previous research and advocacy allies. This essay presents many of the issues that have emerged, which include challenges about the feasibility, justification, and effectiveness of restricting benefits; the risk of a slippery slope; concerns about participant dignity; and finally, distrust about the motives behind promoting and opposing a policy change. The purpose of this review is to increase mutual understanding and respect of different perspectives. The conclusion is that the rationales behind both support and opposition to updating the policies regulating SNAP benefits based on nutrition are fundamentally the same—the belief that a fair and just society cares for and protects vulnerable citizens, which in this case are low-income Americans who need assistance affording healthy food. Recommendations include activities to restore trust between the public health and anti-hunger communities, authentic engagement of SNAP participants in the conversation, and an optional SNAP program that includes both incentives and restrictions.

Am J Prev Med 2017;52(2S2):S199-S205. © 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/4.0/).

INTRODUCTION

Food insecurity is a tragic, prevalent, and preventable problem in the U.S. In 2014, one in seven Americans was food insecure, defined by the U.S. Department of Agriculture (USDA) as having "limited or uncertain ability to acquire acceptable foods in socially acceptable ways."1,2 Although the federal government oversees more than a dozen food assistance programs, the Supplemental Nutrition Assistance Program (SNAP) is the largest, costing nearly $80 billion in Fiscal Year 2013.3 In 2011, SNAP households were composed of 50% adults, 40% children aged <18 years, and 10% seniors aged >60 years.3

Research indicates that SNAP successfully reduces food insecurity3; however, food insecurity is not the only food-related threat facing the U.S. Over the past 3 decades, the nation has experienced an unprecedented rise in diseases linked to poor diet, including obesity, Type 2 diabetes, hypertension, and heart disease. Although there is mixed evidence about a causal relationship between obesity and food insecurity, there is

agreement that food insecurity and diet-related diseases co-occur in a significant number of communities, families, and individuals.3 This fact has forced a national conversation about how to harmonize government efforts to improve nutrition with those to reduce food insecurity.

The 2010 Healthy Hunger-Free Kids Act, as evidenced by its name, reflects the idea that hunger and health must be addressed simultaneously. When it was signed, this law was touted as providing the USDA the first opportunity in 30 years to meaningfully improve all of the

From the Rudd Center for Food Policy and Obesity, University of Connecticut, Hartford, Connecticut

Address correspondence to: Marlene B. Schwartz, PhD, Rudd Center for Food Policy and Obesity, University of Connecticut, 1 Constitution Plaza, Suite 600, Hartford CT 06103. E-mail: marlene.schwartz@uconn.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.2016.09.022

© 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. Am J Prev Med 2017;52(2S2):S199-S205 s199

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

federal food programs that serve children.4 Indeed, over the past several years, researchers and advocates who care about the federal food programs have been watching the USDA release dramatic improvements to the National School Lunch and Breakfast Programs, the Child and Adult Care Food Program, and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).5,6

In the context of observing these nutrition policy updates and evidence-positive effects,7-10 researchers, advocates, and policymakers have turned their attention to improving the nutritional footprint of the largest federal food program, SNAP. The idea of restricting SNAP is not new. Policymakers have proposed restrictions multiple times since the program began, although the USDA has consistently denied all requests for waivers of this type.11 In 2010, however, the conversation about restricting SNAP reached a new level of prominence because New York City requested a waiver from the USDA to conduct a pilot study to test the effect of restricting sugary drinks from purchase using SNAP benefits, and the USDA rejected it.

The media attention to the initial request, and the subsequent denial from the USDA, created a flurry of conversation within the advocacy and scientific antihunger and public health communities.12-14 One surprising outcome was that anti-hunger and public health nutrition groups that typically worked very closely together to strengthen other federal food programs found themselves on opposite sides of the debate. As just one example, the Food Research Action Center published a report in opposition to changing SNAP,15 whereas the Center for Science in the Public Interest organized a letter signed by more than 50 organizations and health experts to Secretary Vilsack to allow pilot tests of restricting sugary drinks from SNAP.16

In subsequent years, the debate has continued in the literature as researchers and advocates have outlined many specific arguments to either support or oppose the idea that SNAP should restrict the purchase of sugary drinks.17-20 The Institute of Medicine referenced the topic of restrictions within SNAP and stated that these policies "raise both practical and economic concerns," "ethical and social concerns," and "may be viewed as patronizing and discriminatory to low-income consu-mers."21 Clearly, there are several layers of arguments to address, but the debate is compounded by growing distrust among the parties involved. This distrust has become toxic and has effectively stalled all efforts by policymakers to change the regulations concerning SNAP to include nutrition standards.

The premise of this paper is that there is a need to develop mutual respect and understanding of how

opposite views of this particular policy can both be based on a desire to create a fair and just society. The paper is organized by themes that have emerged in the debate and presents alternating perspectives under each theme. Though restricting sugary drinks from SNAP has received the most attention, the larger issue of restricting "unhealthy food" is also addressed. The purpose of this analysis is to outline a range of perspectives, acknowledge the validity of different points of view, and inspire willingness to work together to maximize the positive impact of SNAP.

THEME 1: FEASIBILITY

The debate about whether or not to restrict SNAP benefits often begins with arguments that it would be extremely difficult to implement this change. Pomeranz and Chriqui17 review this concern and present potential strategies. The USDA defines and regularly updates which foods are available through WIC, and a similar strategy could be used for SNAP.17 Alternatively, many states judge foods as either necessary or unnecessary through their sales tax laws, and those laws could be used to determine which products are eligible for SNAP.17 For example, a state that exempts food from sales tax might tax sugary drinks and candy because these are not considered "food." Sales tax is added at checkout and the scanners automatically determine which foods are and are not taxable. The same technology could be used to determine which foods can and cannot be purchased with SNAP benefits. Another idea is to create an app, such as the one available for WIC recipients that scans the barcode and tells the shopper whether or not a product is allowable.22

On the other hand, those concerned about feasibility point out that WIC cannot be used as a model for SNAP because the number of foods included in WIC is tiny compared with the number of foods currently eligible for SNAP. Further, this would be inappropriate because WIC was set up as a dietary prescription for a high-risk population (i.e., low-income pregnant women and their young children), not as an income transfer program. In addition, there would be considerable expense associated with training retail employees and educating participants. If a change were made in a single city or state, this would represent a substantial departure from the way this federal program has been managed to date.

THEME 2: JUSTIFICATION

A second theme in the debate is that there is no justification for restricting purchases among SNAP recipients. A report from the Food Research Action

Center states, "those suggesting strategies aimed uniquely at keeping poor people from the normal streams of decision-making and commerce bear a burden of justifying that targeting."15 If SNAP participants are at higher risk of poor diet than the general population, one could justify a policy that applies to SNAP participants but not the rest of society. As a result, there is considerable debate in the literature about the strength of this evidence because this is a difficult empirical question to answer.

The primary methodologic challenge in studying the consequences of SNAP is that people are not randomly assigned to participate. SNAP participants are likely to be systematically different from eligible non-participants. Further, SNAP participants are likely different from higher-income people. With these limitations in mind, a recent review of 25 studies examined the diets of SNAP participants, eligible non-participants, and higher-income individuals.23 Overall caloric intake and consumption of macronutrients and micronutrients were similar between SNAP and income-eligible non-participants. There were differences in Healthy Eating Index scores, with adult SNAP participants consuming a less healthy diet than either comparison group. Children whose families participated in SNAP had similar nutrition quality to income-eligible non-participants, but lower quality than higher-income children. Sugary drink consumption was included in ten of the studies, and the findings comparing SNAP participants with eligible non-participants were mixed; some data suggested higher intake, and other data indicated comparable rates. Overall, the data suggest that SNAP participants consume more sugary drinks than higher-income individuals, but similar amounts as eligible non-participants.

The pattern of sugary drink consumption illustrated by these studies suggests that low-income Americans in general are at higher risk of engaging in this behavior, but there is limited evidence that the action of participating in SNAP (or the characteristics associated with a person who chooses to participate in SNAP) increases sugary drink consumption beyond the risk associated with poverty. Therefore, one can argue that if SNAP benefits are not to blame for additional purchases of sugary drinks, restricting only SNAP purchases in this way is not justified.

Another perspective is that sugary drinks are so toxic that any and all efforts to limit them are justified. A policy to restrict sugary drink purchases with SNAP will at least reach a portion of the low-income population that consumes high levels of sugary drinks and may help lower consumption rates in that subpopulation. Public health advocates who support restricting SNAP

purchases of sugary drinks are focused on singling out the drinks, not singling out SNAP participants. There are other examples of anti-sugary drink policies that only reach a subset of the population, such as restricting these products in schools, hospitals, and government buildings. To reflect the challenge from the Food Research Action Center report quoted above, these policies are not "aimed uniquely" at poor people; they are aimed uniquely at sugary drinks.

THEME 3: EFFECTIVENESS

A third theme in the debate is that a policy to restrict sugary drink purchases shouldn't be implemented because it won't have an impact. Gundersen3 argues that restricting sugary drinks from SNAP won't achieve the desired effect because the majority of recipients can simply substitute their own funds to buy the excluded product. In light of the cost of changing the program and training everyone involved, the burden is on those requesting the change to prove that the benefit justifies the cost of the change. Further, soda sales are already decreasing nationally, so a meaningful decrease due to this policy is unlikely, making the expense of changing SNAP a waste of resources.

An alternative view is that the effectiveness of this restriction on sugary drink purchases and consumption is an empirical question that requires a pilot test or simulation of the policy to answer. It is relevant to note that 34 states apply sales tax to soda, which means that the price will effectively increase when it is purchased with cash because sales tax (when applicable) is not charged when using SNAP.24 This may magnify the impact of the policy change.

Yet another view is that it is not reasonable to demand proof that any single policy will decrease obesity, improve the diets of low-income Americans, or even decrease sugary drink consumption, because multiple policy strategies are needed to reach these ambitious goals. For even the simplest of these goals, reducing sugary drink consumption, organizations including the American Heart Association,25 Healthy Food America,26 and the Center for Science in the Public Interest24 have promoted multiple policies such as removing sugary drinks from schools and government buildings, reformulating products, putting warning labels on cans, imposing taxes, and restricting marketing of these products to youth.27 Although each individual policy is designed to reach a subset of the population, implementing all of these strategies together has the potential to create a meaningful improvement in public health.

THEME 4: SLIPPERY SLOPE

One of the key concerns expressed by the USDA about approving a request to restrict sugary drinks is that it will begin a slippery slope leading to requests to ban all "unhealthy" foods. This is a problem for two reasons. First, USDA will need to rate or rank foods on some type of nutrition scale, and second, it will need to define the boundaries of "healthy" and "unhealthy" foods. These are substantial challenges, as the country does not have an official nutrition scoring system that can be applied to individual foods, and the Dietary Guidelines for Americans emphasize the importance of evaluating the eating pattern as a whole, not individual food items.28 Another concern is that this process will open up the floodgates of food industry lobbying to ensure that their products are not restricted, or alternatively, are incentivized.

An alternative view is that nutrition scoring systems have been developed and are being used successfully in different settings, which can inform the USDA. There are scores and symbols used in the retail environment to designate healthier options (e.g., NuVal, Guiding Stars,30); rankings in food banks to track the nutritional value of the items they distribute (e.g., Choosing Healthy Options Program31); and nutrition standards set by members of the food industry to determine which products are appropriate to market to children (Children's Food and Beverage Advertising Initiative32). The Healthy Eating Index's definition of "empty calories" could be used to identify foods that provide no nutritional value at all and are composed of high amounts of added sugar, saturated fat, or sodium.33 It is undeniable that defining which foods warrant exclusion from SNAP will be challenging; however, there is substantially more experience with nutrition rating now than even 10 years ago, and there are scientific strategies that could inform the USDA.

THEME 5: CONSISTENCY

Arguments about consistency appear throughout the debate. One view is that any program that claims to focus on nutrition, yet permits sugary drinks, is blatantly ignoring decades of research documenting the harm associated with these products.34,35 The USDA clearly states that Americans should "drink water instead of sugary drinks."36 Blondin37 points out that "SNAP is the only federal nutrition assistance program that does not regulate the quality of foods offered and the only one to subsidize the purchase of SSBs." Barnhill18 further illustrates this point by saying, "With its right hand, the federal government funds nutrition education and wellness programs to encourage healthy eating; but with

its left hand, the federal government funds SNAP participants' purchase and consumption of sweetened beverages."

Kass and colleagues19 present an alternative, more nuanced perspective in their analysis of three sugary drink policies (i.e., restricting sales in schools, sugary drink taxes, and restricting purchases with SNAP). They use six ethical considerations: achieve public health benefit; minimize meaningful burdens and harms; reduce morally relevant inequalities and promote justice; ensure fair procedures and accountability; align government policies and programs with evidence-based agency guidelines; and recognize symbolic relevance. Though the authors conclude that restricting sales in school and taxing sugary beverages for everyone pass ethical muster, the SNAP policy does not. The reason is inconsistency— if the goal is to stop government funds in SNAP from being used to purchase sugary drinks, then this restriction must be applied to all types of government funds used to purchase beverages, including cafeterias in all government buildings and all beverages purchased with federal grant funds.

Emily Badger's thoughtful piece in the Washington Post Wonkblog38 makes the point that there is a double standard of making the poor prove they're worthy of government benefits. Badger argues that poor people are expected to prove they are not abusing the funds they receive, but the same is not expected from more-affluent recipients. For example, "we don't drug-test farmers who receive agricultural subsidies; we don't require Pell Grant recipients to prove they are pursuing a degree that will get them a real job one day (sorry, no poetry!) and we don't require families who cash in on the home mortgage interest deduction to prove that they don't use their homes as brothels." From this perspective, consistency would be requiring everyone who receives government benefits to prove they are using the funds wisely.

THEME 6: DIGNITY

Concerns about the stigma of SNAP and participant dignity were among the reasons behind the name change from food stamps and the investment in Electronic Benefit Transfer cards. Gunderson3 expresses concern that adding restrictions to SNAP will stigmatize participants because they "would feel singled out as being irresponsible and incapable of making well-informed food purchases." This increase in stigma would become a threat to participation, and a decline in SNAP participation would in turn increase food insecurity. Indeed, if one looks at all of the bills introduced to limit SNAP use, it appears that low-income Americans can't make any food purchase choices without being criticized

by someone. In addition to efforts to limit sugary drinks, there have also been efforts to disallow "luxury" foods, such as lobster and steak.39

Viewed through this lens, the advocates for leaving SNAP alone are not defending the value of sugary drinks; they are defending the value of being in control of how you spend your money. If the fundamental mission of your work is to protect the basic rights and dignity of people living in poverty, it makes sense that you would not agree with any policy that exerted control over how some citizens spend their money just because they are poor.

THEME 7: DISTRUST

Mutual distrust has hampered productive conversations about SNAP restrictions. Public health advocates suspect that the beverage industry has funded, and therefore influenced, anti-hunger advocates. Brownell and Ludwig14 note, "With billions of dollars at stake annually, the beverage industry was predictably opposed" to the New York waiver request. Ed Cooney, the executive director of the Congressional Hunger Center, said that changes to the SNAP program such as restricting sugary drinks would happen "over my dead body."40 Marion Nestle recounts this statement in Soda Politics and suggests Cooney's sentiment is linked to substantial funding from Coca-Cola, PepsiCo, and the American Beverage Association.41

On the other hand, the passion behind the opposition to restricting SNAP among anti-hunger advocates may be due to another source of distrust—that the legislators who are introducing the policies truly have the best interests of SNAP recipients in mind. The House Committee on Agriculture, led by Committee Chairman Michael Conaway (R-TX), has been "engaged in a top-to-bottom review of the Supplemental Nutrition Assistance Program, the Past, Present, and Future of SNAP."42 The true intent of this review is suspicious in light of House Speaker Paul Ryan's reinforcement of false stereotypes about SNAP, such as stating that recipients are unemployed and the program is filled with fraud, waste, and abuse.43 In the context of this attack, there is valid concern among anti-hunger advocates that the funding for SNAP is threatened and any public discourse that can be interpreted as critical of the program or its participants may be used as justification to shrink the program.

MOVING BEYOND THE ARGUMENTS

First, it is critical to acknowledge that the public health advocates and anti-hunger advocates all believe that their

work will help and protect vulnerable people. Most of the authors cited in this paper have worked on many issues related to food insecurity and nutrition—not just SNAP. Advocates on both sides must give each other the benefit of the doubt and begin the conversation with the mutual understanding that they all want the same end result—a country where every citizen has secure access to adequate amounts of healthy food. To this end, the National Academy of Medicine should convene a committee on SNAP with broad representation in order to facilitate rebuilding trust and collaboration in the field. The committee should write a joint statement on the rights of SNAP participants, develop a set of agreed-upon ethical standards against which proposed policy changes can be evaluated, and evaluate existing research and propose a set of recommendations on how to improve SNAP.

Second, instead of speaking for people who use SNAP and assuming how they will feel and act, they need to be spoken to directly. Very little research has been done asking people who participate in SNAP how they feel about these proposed policies and it is possible that the assumptions about increased embarrassment, confusion, and dropout are not accurate. One could argue the opposite point, that setting up this new rule will provide some relief for participants because the public will know that SNAP is not being used for sugary drinks and will know if they see someone buying these products they are doing so with their "own" funds. Long et al.20 are one of the few groups to actually survey SNAP recipients to get their opinions on the issue, and interestingly, the majority agree that it would be appropriate to restrict sugary drinks from SNAP. Further research is needed to permit SNAP recipients to speak for themselves.

Third, even though U.S. culture places premium value on choice, it must be recognized that there are circumstances under which people prefer to have fewer choices. In Barry Schwartz' book, The Paradox of Choice,44 he explains that people get overwhelmed when faced with too many choices, and in fact, are happier with their decisions when they have fewer options to choose from. This is particularly true in the food domain, where people who want to lose weight will pay other people to set limits for them. Every diet book and program is based on the premise that a specific structure or set of rules will make it easier for people to make healthy choices. Given this, it is possible that some SNAP participants who are interested in making healthier beverage choices would find it easier to follow through on their plan to cut back sugary drink consumption if these products were no longer included and may actually prefer to have a version of SNAP that did not include sugary drinks. As noted earlier, only by speaking with people who participate in

SNAP will the range of reactions to this policy change be known.

Fourth, the language regarding food needs to change. Instead of getting tangled in defining "bad" or "junk" foods, another strategy is to focus on defining products as "food" or "not food." Fortunately, as discussed by Pomeranz and Chriqui,17 many states have already done the work on this by defining taxable and nontaxable items at the grocery store. Another shift in language is thinking about "and" instead of "or." To date, the discussion has implied that the choices are to have incentives or limits. But, if it is not feasible to change the rules for SNAP for everyone, another approach is to combine incentives with limits and provide an alternative program to participants. To examine how potential users of such a program might respond, Leung and colleagues45 collected online survey data from a group of SNAP participants and a group of food-insufficient individuals who do not participate in SNAP.45 Respondents were asked to rate support for an alternative program, SNAP+, which excluded sugary drinks and included incentives for fruits and vegetables. Even at the current benefit level, more than two thirds of SNAP participants and more than 80% of non-participants said they would prefer SNAP+. A next step should be to conduct a pilot test of SNAP+ to assess the proportion of current SNAP recipients who would agree to accept sugary drink restrictions if they also came with incentives for fruits and vegetables, and among those who choose to participate, how overall purchases and diet quality change. This option respects the decision-making power of SNAP participants by allowing them to choose whether to try the enhanced program.

CONCLUSIONS

In the question of restricting sugary drinks from SNAP, it is important to recognize that one can argue either position based on ethical principles. From one perspective, it is not ethical to restrict federal funds for SNAP from purchasing sugary drinks and not similarly restrict all other sources of federal funding. But from another perspective, it is not ethical to permit federal funds specifically designated to improve nutrition among low-income people to be used to purchase products that have been proven to be harmful to human health. In order to move beyond the stalemate of the current debate, advocates and researchers who care about the health and well-being of low-income Americans must listen to all perspectives and work together to identify a range of acceptable strategies that consider not only the health but the dignity of the people they are committed to serving.

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 author and do not necessarily represent the official position of the Physicians Committee for Responsible Medicine.

No external funding was provided to the author to support work on this study. Concepts in this paper previously appeared in a commentary by the author published in the Journal of the American Medical Association Internal Medicine in 2016.46

No financial disclosures were reported by the author of this paper.

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