1. Making SNAP More Healthful Punam Ohri-Vachaspati, PhD, RD Arizona State University Karen Sell, RD Arizona Department of Health Services Collaborators: Christopher Wharton, PhD; Will Humble, MPH; Robin DeWeese, MS; Wesley Tucker, MS

2. Outline o Why should we care? o SNAP’s impact on health status o SNAP’s impact on diet quality o How prevalent are unhealthy purchases among SNAP shoppers o Who can make changes to SNAP o Suggested Strategies for Improving SNAP

3. Why Should We Care? o SNAP targets household in most need o In 2011, SNAP included  Over 44 million participants  Over $71 billion in benefits Increased from $50 billion in 2009 o Greater scrutiny of federal assistance programs  Effectiveness  Impact on health o Opportunity to impact diets of 1 in 7 Americans www.fns.usda.gov.

4. SNAP Users Have Less Healthy Diets o Children from SNAP households eat more calorie-rich foods o SNAP participants consume  more solid fats, added sugars  fewer fruits and vegetables and whole grain  more soda (and sugar sweetened beverages) Cole and Fox, USDA 2008; Leung and Viallamor, Public Health Nutr 2011

5. SNAP Users Purchase Less Healthy Foods o SNAP households buy  more than twice as much SSB compared to WIC only households  70% of SSB purchased with SNAP benefits o Estimated SSB purchase by SNAP users - over $2 billion / year Andreyeva et al., Am J Prev Med 2012;

6. Higher Risk of Obesity Among SNAP Users Higher rates of overweight and obesity among  Women participating in SNAP (especially among those who are food insecure)  Young girls from SNAP households  Male SNAP participants Ver Ploeg and Ralston, USDA 2008; Leung and Viallamor, Public Health Nutr 2011;

7. Who Can Make Changes to SNAP o Two mechanisms at State level  changing policies that do not have an impact on federal requirements for the functioning of the program – EBT cards at farmers’ markets  applying for a waiver (from the FNS) related to federal SNAP rules if the proposed change would result in more efficient administration of the program  To date, no waivers have been granted that affect policies related to participants’ food choices or food environment

8. Strategies for Making SNAP Healthier 1. 1.Improving SNAP Participant’s Access to Healthy Foods 2. 2.Incentivizing Purchase of Healthy Foods for SNAP Participants 3. 3.Restricting Purchase of Unhealthy Foods With EBT Cards 4. 4.Including Public Health Approaches to Expand SNAP-Ed Outreach

9. Improving SNAP Participant’s Access to Healthy Foods Improving SNAP Participant’s Access to Healthy Foods Recommendations State/ Federal Initiative Evidence a Political Feasibility b Implement n Feasibility c Require SNAP vendors to carry healthier fare Federal (State, indirectly) MediumWeakMedium Encourage healthier food retailers to locate in underserved communities StateMediumStrongMedium Accept SNAP benefits at farmers’ markets StateStrong Innovative modes for redeeming SNAP benefits FederalN/AMediumTBD a Based on research studies and expert recommendations and commentary. b Based on state and federal political and administrative support and potential acceptability to advocates and stakeholders. c Based on level of complexity in implementation and cost of implementation.

10. Possible ObjectionsArguments More stringent guidelines will make it harder to buy food using EBT in food deserts. Improved selection at stores in food deserts will improve the local food environment. Improved selection at stores will increase stores’ revenues. Farmers’ markets in low- income areas are not sustainable. SNAP redemption at farmers’ markets has been increasing. Wireless/EBT terminals increase sales. Encouraging farmers’ markets to locate in low-income neighborhoods and providing culturally appropriate means of promotion and transport can improve participation rates. Improving SNAP Participant’s Access to Healthy Foods Improving SNAP Participant’s Access to Healthy Foods

11. Incentivizing the Purchase of Healthy Foods for SNAP Participants Recommendations State/ Federal Initiative Evidence a Political Feasibility b Implement n Feasibility c Provide POS incentives for buying healthy foods Federal/ State Under study Strong Under study Incentivize use of EBT at farmers’ markets State / Local MediumStrong a Based on research studies and expert recommendations and commentary. b Based on state and federal political and administrative support and potential acceptability to advocates and stakeholders. c Based on level of complexity in implementation and cost of implementation.

12. Incentivizing the Purchase of Healthy Foods for SNAP Participants Possible ObjectionsArguments Increasing fruit/vegetable intake will not reduce both calorie intake and weight. Fruit/vegetable intake has benefits beyond weight loss, such as reduced cancer and other chronic disease risks. Education can accompany the promotion of fruit/vegetable intake to reduce consumption of unhealthy foods, reduce caloric intake, and result in weight loss. More money in SNAP benefits for fruit/vegetable will free up money for unhealthy foods. Being studied through a USDA-funded pilot program. Less likely at farmers’ markets, where most SNAP-eligible foods are fruit/vegetables. Since staples will not have to be sacrificed, more purchases of fruits/vegetables at stores are possible.

13. Restricting Purchase of Unhealthy Foods With EBT Cards Recommendations State/ Federal Initiative Evidence a Political Feasibility b Implement n Feasibility c Exclude energy-dense, nutrient-poor foods FederalStrongWeakLow Exclude sweetened beverages FederalStrongWeakMedium a Based on research studies and expert recommendations and commentary. b Based on state and federal political and administrative support and potential acceptability to advocates and stakeholders. c Based on level of complexity in implementation and cost of implementation.

14. Possible ObjectionsArguments SNAP participants will experience loss of freedom of choice.  Restrictions are not absolute; SNAP participants can continue to purchase sweetened beverages using non- SNAP funds.  Modest restrictions are justified, given the overall program goal of improving participants’ diet.  Precedents exist with the exclusion of certain foods within SNAP (hot foods, prepared foods) and other federal nutrition programs such as WIC and NSLP. Will result in embarrassment and stigmatization and reduce SNAP participation.  SNAP restricts other purchases.  Pilots needed to assess additional stigmatization.  Assess alternate mechanisms for identifying qualifying items  Stigma is not the top reason for why eligible participants do not participate in SNAP. Restricting Purchase of Unhealthy Foods With EBT Cards

15. Possible ObjectionsArguments Increased program complexities and cost.  WIC restricts purchases to specific items  Pilots needed to study implementation challenges  Experiment with alternate ways to identify qualifying foods No standards to judge food healthfulness.  Other federal nutrition programs such as NSLP restrict foods based on the USDA’s definition of foods of minimum nutritional value.  WIC packages include only healthy foods. SNAP participants will use other resources to purchase SSB.  Food purchased with SNAP benefits is tax-free. Sweetened beverages will cost more if purchased with other resources.  Sweetened-beverage consumption is price-sensitive; with higher costs, consumption is likely to go down. Restricting Purchase of Unhealthy Foods With EBT Cards

16. Including Public Health Approaches to Expand SNAP-Ed Outreach Recommendations State/ Federal Initiative Evidence a Political Feasibility b Implement n Feasibility c Combine nutrition education with public health approaches FederalStrongMedium Create guidelines that allow promotion of healthy foods and dissuasion of energy- dense, nutrient-poor foods FederalStrongLowHigh Use multimedia approaches to deliver messages Federal/ State Strong High a Based on research studies and expert recommendations and commentary. b Based on state and federal political and administrative support and potential acceptability to advocates and stakeholders. c Based on level of complexity in implementation and cost of implementation.

17. Including Public Health Approaches to Expand SNAP-Ed Outreach Possible ObjectionsArguments Adding incorporation of public health approach will require retraining program deliverers.  SNAP-Ed has an organized infrastructure to retrain and retool staff.  Many communities are already making the transition from education- and service-based initiatives to adding policy, systems, and environmental approaches. Discouraging consumption of unhealthy choices may be considered paternalistic.  Restrictions are not absolute; SNAP participants can continue to purchase sweetened beverages using non-SNAP funds.  Modest restrictions are justified, given the overall program goal of improving participants’ diet.  Precedents exist with the exclusion of certain foods within SNAP (hot foods, prepared foods) and other federal nutrition programs such as WIC and NSLP.

18. White Paper http://www.snaptohealth.org/wp- content/uploads/2012/02/SNAP_White _Paper_FINAL.pdf

19. Thank You! Contact Information: Punam.Ohri-Vachaspati@asu.eduKaren.Sell@azdhs.gov