Preventive Medicine Column
Dr. David L. Katz
SNAP (Supplemental Nutrition Assistance Program), formerly known as Food Stamps, has of late been much in the news. Competing views of SNAP figure prominently in the Farm Bill quagmire; the harsh economy over recent years has landed fully one in seven American families on its rolls; the Sequester is bumping people off its rolls, with worrisome implications; and the poverty that warrants such assistance is far more prevalent, if fleetingly so, than most of us realize.
Poor dietary pattern is at the very top of the list of the leading causes of chronic disease and premature death. Poor diets and poor health are more prevalent among SNAP beneficiaries than the public at large. Side-stepping any relevant parsing of all the reasons why, we might simply acknowledge that we- the American taxpayers- send the Feds about $100 billion annually to underwrite SNAP so that poor people can choose poor food to get to poor health. We then spend a whole lot more money than that through Medicaid to pay the costs of all that disease care. Who wins in this scenario?
Not a soul-which may explain why SNAP evokes rather passionate opposition from some quarters. But if SNAP as it exists is encumbered by unintended consequences, and bumping families off SNAP simply adds insult to injury while harming the economy at large and hindering human potential- where might we go from here? Along a neglected middle path.
First, if it makes no sense to use public funds to help people eat the junk that propagates obesity and chronic disease and drives up costs, then it makes no sense in any context. Tax dollars underwrite public school food, too, for instance. Why should I spend money to help make more kids diabetic? It seems to me the same camp that opposes SNAP opposes the “nanny state” intrusion of such things as getting soda and cupcakes out of the schools. Let’s go in for a pound, and tether public funds for sustenance to real food everywhere. Such a rising tide might help lift all boats by raising the quality of our food supply in all of its public incarnations and lifting the currently rather deplorable standard of our national health.
Second, if we are going to consider some standard of nutritional quality to guide what is permissible and what is not for SNAP at least, if not other quarters, we need an objective measure to avoid bogging down in interminable squabbling based on competing opinions, and conflicted interests.
Many such approaches exist, and others could be devised, but as it happens, I am the principal inventor of the only nutritional guidance system in the world (to the best of my knowledge) thus far shown to correlate directly with health outcomes, including all-cause mortality. Research just presented at the American Public Health Association meeting further suggests that the system, which uses a 1-100 scale, the higher the number, the more nutritious the food, facilitates choices better than all of the alternatives. And out in the real world, the system, called NuVal- which has been applied to roughly 100,000 foods so far- is associated with stunning effects-such as the loss of over 100 lbs just by trading up the quality of grocery choices in every aisle of the supermarket. Such a system could be applied to establish objective thresholds of nutritional quality by category for which SNAP dollars could be used.
Third, we might try spending a little to save a lot. SNAP seems to invite its detractors to swing a big stick, but why not consider the far more appetizing carrot? We might link a comprehensive, soup-to-nuts program of financial incentives to an objective and validated measure of nutritional quality. Buy a bread in the bottom quartile of bread scores, in other words, and your dollar is worth a dollar. Buy a bread in the top quartile, and your dollar is worth two dollars. Such thinking is already applied to produce, but there are many barriers to produce intake other than cost. Extending this approach to all foods, based on an objective measure of nutritional quality, would provide far greater leverage.
Leverage to what end? There would not need to be much shift in food purchases to the better before the chronic disease needle started to move. All available information suggests it would cost vastly less to incentivize the selection of better breads, and chips, and pasta sauces- than to keep paying for visits to the endocrinologist, coronary bypass and bariatric surgery. Everyone, in other words, would win- and it’s an approach even ardent civil libertarians could love, because it’s all carrot, no stick.
I believe food stamps could be reimagined, and the result could be a win for all concerned. But we let such opportunities languish in a world where ideology trumps epidemiology when it should be the other way around. Opportunities languish because of the common crackle of discord, and the pop to opposing corners. I believe if we could just get past such crackle and pop, fixing food stamps and much else that ails us- could be a SNAP.
Dr. David L. Katz