Diet

Nutritional Pearls: Food Benefit Programs

Mark is a 32-year-old overweight man struggling to lose weight. Mark is currently participating in a food benefit program and expresses to you that he would like to eat more fruit and vegetables, but he tends to purchase more processed, less healthful foods because of their lower prices.

How do you advise your patient?
(Answer and discussion on next page)

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Answer: Even programs incentivizing healthful food options don’t always increase fruit and vegetable intake.

Overweight and obesity continue to be a worldwide health problem, and those most likely to be overweight or obese tend to be those with lower incomes. There's been quite a bit of discussion about why that might be, with theories ranging from a lack of access to healthier foods ("food deserts") to cost ("eating healthy is expensive"). Yet both ideas are not well supported by the research: for example, limiting the number of fast-food restaurants or increasing the number of supermarkets in low-income areas doesn't necessarily mean people will eat more fruits and vegetables. Nor is it really all that much more expensive to eat healthy than it is to go to McDonald's.

On the other hand, making fresh fruit available for free to low-income workers to eat during their lunch break meant that not only did they eat more fruit themselves, but also they actually purchased more fruit for themselves, and more vegetables were served in their home. You may have seen other proposals in the news recently, including the idea of "fruit and vegetable prescriptions," and a study that showed that providing financial incentives in the form of vouchers to those who purchased fresh fruit using their electronic benefit transfer (EBT) cards at farmer's markets actually increased the amount of fruit the users purchased.
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As you might expect, policymakers are interested in improving the diets of low-income individuals: Healthy people contribute more to the economy and utilize health and social services less than those who are less healthy. A good bit of that discussion has focused on the food choices made by those on the Supplemental Nutrition Assistance Program (SNAP)—formerly known as "food stamps"—a benefit program that provides funding via an EBT card that limits the SNAP user from purchasing anything with their benefits other than a fairly broad selection of foods that includes sweets, pastries, and sugar-sweetened beverages.

The Research

If financial incentives help induce people to purchase more fruits and vegetables, what if you excluded those sweets, pastries, and beverages from coverage? Would people choose more fruits and vegetables instead? A team of researchers based in Minnesota designed a study to test financial incentives, restricting people's choices, and incentives and restrictions together to see how people's consumption might change.

The authors note that "for legal reasons it is currently not possible to alter the practices of the actual SNAP program." To make their study as close as possible to the real thing, they recruited 265 families who were nearly eligible for SNAP or were eligible for SNAP but were not participating at the time to join their study. The families were given debit cards, and every 4 weeks for the duration of the 12-week study, the authors deposited the average SNAP benefit amount for the participants' family size on the card. To monitor usage of the card, the participants were required to turn in their receipts for each time they used the card (those who misused the card were excluded from analysis).

The families were randomly assigned to 1 of 4 groups:

  • Control Group: This group was allowed to use their card to purchase the same items as are permitted on the actual SNAP program.

  • Incentive Group: For all of the fruits and vegetables this group purchased, 30% of the purchase price was refunded to the card, and the cardholder was notified of the refund by email or text. Standard SNAP purchasing restrictions applied.

  • Restriction Group: This group was allowed to purchase the same items as permitted on the actual SNAP program, with the exception of sugar-sweetened beverages (including soft drinks, fruit drinks, and sports/energy drinks), candy of any kind, and prepared sweet baked goods (such as pies, cakes, or cookies), which they were not permitted to purchase.

  • Incentive Plus Restriction: Both the fruit and vegetable financial incentive AND the prohibition on sugar-sweetened beverages, etc., as in the Restriction Group.

In the first and last weeks of the study, the participants responded to 3 separate 24-hour dietary recalls, which allowed the investigators to assess not only fruit and vegetable intake and the intake of restricted foods, but also the participants' diet as a whole.

The Results

The authors found that compared with those in the Control Group, those in the Restriction Group averaged consuming about 100 fewer calories per day (while the Control Group increased their intake by 80 calories), cut the added sugar in their diets almost 3 times more than the Control Group did, and slightly increased (by about 1/10 of a serving) their solid fruit score. On the other hand, they still drank about the same amount of sugar-sweetened beverages as they had at the start of the study and cut their intake of the restricted foods by only about 0.1 serving.

Those in the Incentive Group cut their calories by only about 30 calories and continued consuming about the same amount of the foods on the Restricted list while cutting their sugar-sweetened beverage intake by about 0.2 servings. They increased their fruit intake by about 0.2 servings, but their vegetable intake remained about the same.

Those in the Incentive Plus Restriction Group, however, made some of the greatest changes to their diet: about 96 fewer calories per day, the greatest decrease in added sugars in their diet (about 9 times that of the Control Group), the largest decrease in consumption of Restricted foods, and the largest increase in the quality of their overall diet. They did not, however, improve their intake of solid fruit any more than the Incentive Group, and their intake of vegetables (when potatoes were included) actually decreased slightly (by 0.1 serving). Even when considered together, their intake of fruits and vegetables (excluding potatoes and fruit juices) did not increase as much as those in the Incentive Group.

What’s the “Take-Home”?

One would think that the Incentive Plus Restriction Group would have eaten far more fruits and vegetables because they were given financial incentive to purchase them, and they were unable to spend that money on sweets and sugar-sweetened beverages. Yet they did not.

Here's the problem: While there were a few single people in the study, the money on those debit cards was mostly used to purchase food not for an individual but for a family. The dietary questionnaires only covered the intake of the person actually doing the grocery shopping—not what their family ate. I'm not sure that it's fair to assume that what one person in the family eats is going to be representative of the diets of the whole family, so I would take these results with a large grain of salt.

Reference:

Reference:
Harnack L, Oakes JM, Elbel B, Beatty T, Rydell S, French S. Effects of subsidies and prohibitions on nutrition in a food benefit program: a randomized clinical trial [published online September 19, 2016]. JAMA Intern Med. doi:10.1001/jamainternmed.2016.5633.