Obesity is one of the leading health challenges in the U.S., so why is the federal government subsidizing it among low-income Americans?
This question comes to mind in response to President Biden's efforts to increase benefits for participants in the Supplemental Nutrition Assistance Program (SNAP), the nation's largest food relief program for low-income individuals. However, any changes in SNAP -- formerly known as food stamps -- should be tied to reforms that promote healthier eating. Public health experts, big-city mayors, and even SNAP beneficiaries support such a move.
The Role of SNAP in Rising Obesity Rates
The country's rising obesity rate provides the backdrop to the need for SNAP reform. More than 42% of American adults, and nearly 20% of children are obese, leaving the U.S. with the highest obesity rate in the world among nations with at least 5 million people.
While people typically face an increased risk of obesity-related conditions over time (such as hypertension, diabetes, and cardiovascular disease, as well as several types of cancer, including of the breast, brain, liver, and pancreas), we've seen during the COVID-19 pandemic that the health implications of obesity can be immediate. Obesity is associated with a greater risk of COVID-19-related hospital admissions, intensive care, and mortality.
More than 40 million Americans benefited from SNAP in fiscal year 2021, and almost half (43%) of beneficiaries are children. Given the program's size, it could be a powerful vehicle for healthier eating and a lower obesity rate.
Instead, it is contributing to the obesity epidemic. Beyond a prohibition on the purchase of hot food, alcohol, tobacco products, vitamins, or medicines, virtually any other food or beverage item -- including soda, candies, and processed meats -- can be purchased with SNAP benefits.
The result is high levels of SNAP spending on many of the foods and beverages at the root of the nation's obesity epidemic. About 20 cents of every SNAP dollar goes toward sweetened beverages, desserts, salty snacks, candy, and sugar, according to a report commissioned by the U.S. Department of Agriculture (USDA). Soft drinks, potato chips, and processed meats are among the top ten items purchased with SNAP benefits. Regular consumption of these calorically dense and nutritionally poor foods is associated with an increased risk of obesity, cardiometabolic conditions, and cancer. Processed meat has been classified by the World Health Organization as a Group 1 human carcinogen, putting it in the same category as asbestos and tobacco.
Permitting unlimited purchases of nutrient-poor food is emblematic of how SNAP fails its beneficiaries and contributes to elevated obesity rates in lower-income individuals -- rates that are nearly eight percentage points higher than among those with higher incomes, according to the CDC. SNAP participation is also associated with increased body weight, and the program's beneficiaries have lower dietary quality and worse health indicators than those who are eligible for the program but don't participate.
In a study conducted at the Harvard School of Public Health, researchers compared the diets of SNAP participants to low-income adults not receiving SNAP benefits. The researchers found SNAP participants consumed 39% fewer servings of whole grains and 46% more servings of red meat. Among women, SNAP participants consumed 61% more sugar-sweetened beverages than non-participants.
Policy Change As a Remedy
One option to help address this issue is to limit the use of SNAP benefits to products that meet rigorous nutritional standards. In 2013, 18 mayors endorsed this idea. The mayors -- including Michael Bloomberg, Cory Booker, and Rahm Emanuel -- represented most of the country's largest cities. In a letter, they called for testing and evaluating approaches that would limit SNAP's subsidization of products such as sugar-sweetened beverages.
Similarly, the lead researcher on the Harvard study said, "Further consideration needs to be given to policies to create incentives for SNAP participants to access and purchase healthier foods, and to limit the purchase of unhealthy food with SNAP benefits."
Restrictions on benefits-eligible foods would not be unique to SNAP. Other federal programs, such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), prohibit beneficiaries from purchasing candy, soda, or snack foods. After this change was made to WIC in 2009, researchers at Yale University found that WIC-authorized stores in Connecticut began carrying more healthy food options -- a development that may be replicated with SNAP purchasing reforms. Such restrictions are likely one reason why participation in WIC is not correlated with increased body mass index.
While some advocacy groups oppose purchasing restrictions on the grounds that they would stigmatize SNAP beneficiaries, beneficiaries see the issue differently. A statewide survey of SNAP participants in California found 74% support for a ban on using the program's benefits for soda purchases. Another survey of more than 400 SNAP beneficiaries found 54% of respondents supporting such a ban. And close to half of those who opposed the ban said they would support it if it involved providing additional benefits to purchase healthy foods.
Those extra benefits were at the heart of a pilot project the USDA launched in Hampden County, Massachusetts in 2011. About 7,500 of households receiving SNAP benefits received an extra 30 cents for every dollar of assistance spent on fruits and vegetables at participating retailers. The effect? Consumption of fruits and vegetables was 26% higher among those in the pilot project relative to those who were not.
Poor dietary patterns, and the resulting obesity, have been steadily eroding the health of the U.S. population for decades. COVID-19 has illuminated the urgent need to address obesity-related health risks, especially in economically disadvantaged communities. Reducing those risks through fundamental changes to how SNAP benefits are utilized is long overdue.
Vanita Rahman, MD, is the Clinic Director at the Barnard Medical Center, a clinical instructor in medicine at the George Washington University School of Medicine, and author of Stronger with Plants. Matthew Rees is editor of the Food and Health Facts newsletter and a senior fellow at Dartmouth's Tuck School of Business.