Friday, December 21, 2012

The Supplemental Nutrition Assistance Program: Failing To Improve Nutrition - Alana Calise

There is some evidence that American citizens reviving food stamps from the Supplemental Nutrition Assistance Program (SNAP) are becoming obese as a result of being enrolled in the SNAP program (Ver Ploeg 2008).  Interventions aimed at reducing obesity rates, reducing spending on junk food, and increasing spending on healthy foods among SNAP  recipients have failed to encourage SNAP recipients to consume the recommended daily value of fruits, vegetables, and other healthy foods (Herman 2008, Blumenthal 2012).  The reason that the SNAP interventions are failing is because of the flawed approach interventionists are taking to reduce obesity and increase healthy food spending. The two main approaches to increasing healthy food spending are providing financial incentives to abate the high cost of nutrient-rich foods and providing educational tools to encourage healthy eating habits among SNAP recipients (, Herman 2008, Campbell 2004).  However, the approaches fail to take into account the unavailability of healthy food in low-income neighborhoods where people likely purchase food with SNAP funds. Failure to utilize the health belief model, psychological reactants theory, and social learning theories has led to the failure of SNAP interventions approaches.
Increasing the amount of money allocated to SNAP recipients and providing financial incentives when a SNAP recipient did purchase healthy foods did not encourage SNAP recipients to consume the recommended daily value of fruits and vegetables (Guthrie 2007). Alternative interventions have included offering a pre-order grocery package pickup for SNAP recipients, providing SNAP recipients with suggested healthy food budgets, and educating SNAP recipients about nutrition and portion control (Blumenthal 2012, Campbell 2004)  All of the aforementioned interventions seek to encourage SNAP recipients to increase their nutritious food spending and consumption, but none have been successful.
The current intervention approaches are flawed.  There is an assumption that SNAP recipients are somehow different from the rest of the population and need extra encouragement to eat healthy foods.  Healthy lifestyle habits are decreasing across America (King 2009).  Research shows that receiving SNAP funds increases the likelihood that a non-elderly female will become obese by two to ten percent, depending on the length of participation in SNAP. However, children, non-elderly males, and the elderly who receive SNAP benefits do not have an increased likelihood of becoming obese (Ploeg 2008).  National studies show that over the last 16 years, the percentage of obese adults has increased, the percentage of adults who report being physically active has decreased, and the percentage of adults consuming healthy fruits and vegetables has decreased (King 2009). Non-elderly females only comprise 28 percent of SNAP beneficiaries (Ploeg 2008).  Therefore, a majority of SNAP participants are not more obese than the rest of America and the connection between obesity and SNAP is exaggerated, if a connection exists at all.  However, there is some indication that SNAP recipients are using SNAP funds on non-nutritive junk food. For example, 69 billion dollars in SNAP funding was allocated to qualified Americans in 2011.  It is expected that four billion dollars of SNAP funds will be spent on carbonated soft drinks (Shenkin 2010). The purpose of SNAP exists in the title: to be a nutrition assistance program.  Carbonated soft drinks are not nutritious.  Therefore, there is a place for public health interventions to attempt to increase the percentage of SNAP funds that are spent on healthy foods. If a successful intervention does not include increasing SNAP financial incentives or educating only the SNAP population, the intervention could have broad positive implications for those not receiving SNAP benefits.
Lack of Access to Supermarkets
The goal of the implemented and proposed SNAP interventions is to increase the percentage of healthy foods that SNAP recipients purchase and consume. (Blumenthal 2012). Early SNAP campaigns failed to achieve the goal of getting Americans to eat more healthy fruits and vegetables (Guthrie 2007). In order to qualify for SNAP benefits, subscribers and their immediate family members must have an income below the poverty line (Eslami 2012, Zedelwski 2009). Residents of low-income neighborhoods in the United States lack access to supermarkets and fresh, healthful food (Ploeg 2010). Convenience stores and fast-food restaurants offering calorie-dense, low-nutrient foods are most prevalent in low-income neighborhoods (Larson 2009).  Even if SNAP recipients desired to purchase healthy foods with their SNAP benefits, the inconvenience of traveling is prohibitive. A majority of SNAP participants live approximately two miles from the nearest supermarket.  If SNAP recipients travel to a supermarket, the distance traveled is approximately five miles. The close proximity of a supermarket does not necessarily mean that the nearest supermarket will be the most affordable for SNAP recipients (Ploeg 2010). Promoting the purchase of healthy foods with financial incentives is illogical if healthy food is not accessible.
In order for people to perceive obesity as a risk and perceive purchasing healthy foods as a benefit to overcome this risk, they must be knowledgeable about the link between obesity and healthy eating.  Low-income families are less knowledgeable about healthy eating habits (Aguilar 2010). To overcome this issue, SNAP participants may be provided with “low-cost bowls and dishes with visual graphics that represent recommended portion size” in the future (Blumenthal 2012).  This intervention is complicated by the fact that fresh, healthy foods are not readily available for purchase in low-income neighborhoods.  Pre-packaged, calorie-dense, non-nutritive, and inexpensive foods are readily available in low-income neighborhoods.  The availability of educational bowls and dishes is useless unless healthy foods are available. 
Critique 1: Failure to Address the Health Belief Model
One of the intervention approaches proposed was to set up a program to allow SNAP recipients to pre-order food baskets. This would eliminate the need for recipients to make multiple trips to distant grocery stores, addressing the lack of access to healthy foods.  However, this intervention fails to take into account the Health Belief Model (HBM). The HBM proposes that behavior is an outcome of perceived susceptibility to a health problem, perceived severity of the consequences of a health problem, perceived benefits in taking action to overcome a health problem, perceived barriers to overcoming a health problem, cues to action that motivate a person to act to overcome a health problem, and self-efficacy, or a person’s belief in her ability to take action to overcome a health problem (Edberg 2007).  In order for a SNAP recipient to take on the task of ordering a food basket and traveling to pick the food basket up, the perceived risk of obesity must be present and severe. Otherwise, no action will be taken to improve healthy food spending. There will be no link between the benefits of traveling to purchase healthy food and lowering obesity risk. No cue to action or self-efficacy will occur.
  Conversely, if the risk of obesity is perceived as severe and the benefits of travel are maximized to induce a healthy food purchasing behavior, the high cost of food at supermarkets may be a barrier to act even if the inconvenience to travel is somewhat minimized (Edberg 2007). The perceived risk of obesity and the desire to overcome this risk is a cue to action only if a SNAP recipient believes that traveling to pick up an order at the grocery store will be beneficial.
Educating SNAP recipients on healthy eating habits and lowering the risk of obesity has only shown to increase knowledge.  An increase in nutritive food consumption has not been shown (Campbell 2004). If education is improved, perceived susceptibility to obesity, severity of negative health consequences, benefits of healthy eating, a reduction in knowledge barriers, and self-efficacy have been addressed. The cue to action is absent from educational initiatives.  This is likely due to the unavailability of healthy foods in low-income areas (Larson 2009).
Critique 2: Failure to Address Psychological Reactants
Humans are wired to hold their behavioral freedoms in high regard. When a behavioral freedom is threatened, people are motivated to act to regain control of their behavioral freedom (Brehm 1966).  Maintaining control over all behaviors is a driving force of human motivation to act. When people are presented with an intervention that threatens their behavioral freedom, the human instinct is to regain control by doing the opposite of what an intervention proposes (Brehm 1966).  The distribution of portion-control bowls and plates is an example of an educational intervention aimed at controlling the behavior of SNAP recipients.  When SNAP recipients receive the bowls and plates, they are going to feel as if someone is trying to force them to give up control of established eating habits and eating behaviors.  In order to regain control of their own eating behaviors, recipients of the bowls and plates are likely to not utilize the bowls and plates for portion control. There is a possibility that people will overeat in response to receiving the bowls and plates as a negative reaction to being told how much to eat. Even if overeating is not the response to regain control, humans will try and restore their behavioral freedom to eat self-determined portions of food (Burgoon 2002).
An argument is that SNAP funds are being wasted on high-calorie, low-nutrient foods. If psychological reactants theory leads people to throw out or permanently shelve their portion-control plates and bowls, more federal dollars will be wasted on a failed intervention to drive down obesity rates and promote healthy eating habits among SNAP recipients.
Critique 3: The Junk Food Industry is Successful When Utilizing Social Learning Theory
All interventions aimed at increasing the percentage of fruits and vegetables that are purchased with SNAP funds fail to take into account social learning theory.  Social learning theory implies that humans behave in a certain way because they perceive other humans as behaving in a certain way (DeFleur 1989).  SNAP interventions target humans on an individual level and fail to take into account the possibility that people behave in a way that is influenced on a social or group level. 
Low-income communities are the target of many junk-food advertisements. Frequent exposure to junk food advertising combined with the lack of affordable, healthy foods contributes to the problem of obesity in low income neighborhoods (Shaffer 2006). A social learning theory method employed by junk food advertisers is to give free samples of junk food to outgoing children. Then, other children see their popular peers eating the free junk food and they desire junk food as well (Shaffer 2006). In low-income communities with sparse opportunities for healthy food purchases, adult may see other adults purchasing readily available and highly advertised junk food at the convenience store.  If buying junk food is rewarding because it satisfies hunger, then the habit of purchasing junk food may become permanent (DeFleur 1989). Social learning theory is based on this process of observing an action, identifying personally with the model of behavior, realizing the benefits of the modeled behavior, remembering the behavior when in similar circumstances, reproducing the behavior, and repeating the behavior if positively reinforced (DeFleur 1989).
SNAP interventions that target individual food purchasing behaviors are not effective because of the failure to apply social learning theory. Providing individuals with more money to afford healthy foods, providing incentives for healthy food purchases, providing pre-packaged grocery orders, and providing educational portion-control bowls and plates will not lead individuals to consume a higher percentage of healthy foods. The individual-level purchasing power and portion control interventions will be ineffective because SNAP participants will still engage in junk food purchasing habits that are modeled. More money may be spent on junk food if it is given to SNAP participants because that is a behavior that is modeled and repeated. Even if SNAP recipients did travel to food markets with healthy food options, they would likely be traveling away from their low-income home areas. Distancing the model from the group whose behaviors an intervention desires to change is ineffective. Additionally, pre-packaging SNAP purchases at grocery stores makes healthy food purchases a secret by having healthy food hidden and bagged by the time a SNAP recipient arrives at the grocery store.
Alternative: An Effective Intervention to Increase Healthy Food Spending
A new proposed intervention to effectively increase the percentage of SNAP funds that are spent on healthy foods will involves targeted advertising campaigns that take the health belief model, psychological reactants theory, and the social learning theory into account.  However, it is likely that no intervention will be effective if access to healthy foods is not improved in low-income areas where a significant percentage of the population are SNAP recipients (Eslami 2010). Therefore, I propose that a permanent fresh-food market is installed near the center of low-income areas with inconvenient access to distant supermarkets (Larson 2009, Ploeg 2010). In order to promote attendance at the fresh food market, an advertising campaign must be developed to promote healthy food purchases and healthy eating habits while accounting for the health belief model, psychological reactant theory, and social learning theory barriers.
Since the only SNAP recipients with a statistically significant increase in obesity rates as a result of receiving SNAP are non-elderly females, a targeted advertisement campaign directed at single non-elderly females and non-elderly females who have families will be developed. The adverting campaign will make use of print and digital media sources with a before and after theme. The before portion of the advertisement will depict a non-elderly female who is suffering from negative health consequences as a result of consuming non-nutritive foods. The after portion of the advertisement will depict the same non-elderly female who adopted healthy eating habits and is free of negative health consequences.  There are several negative health outcomes that can be portrayed in an effort to reduce the amount of junk food purchased with SNAP funds. The negative health outcomes portrayed as a result of eating unhealthy foods can include obesity, a lack of energy to attend to family responsibilities, reliance on a diabetes blood glucose meter, and other negative health consequences.  The second portion of the advertisement will show the same individual who has lost weight, is an active participant in family activities, no longer relies on insulin, and experiences other positive health benefits.  The advertisement does not have to put food in the forefront of the ad, but an unhealthy person surrounded by junk foods available at the local convenience store contrasted with the same healthy person bringing home paper bags of fresh, healthy foods will be sufficient to get the message across. The intervention proposed will inspire SNAP recipients to purchase more healthy foods in order to achieve positive health outcomes.  The advertisements need not necessarily say “buy healthy food with SNAP funds.”  It can be beneficial to all members of society to purchase more healthy foods, especially non-elderly females. However, targeting the advertisements in areas where a high proportion of the population in enrolled in SNAP will ensure that the target audience, SNAP recipients, is reached.
Health belief model: Changing Perceptions and Improving Self-Efficacy
The proposed intervention will guide healthy food purchasing behaviors based on the health belief model (Edberg 2007). The advertising campaign will depict a model that had former unhealthy eating habits and the negative health effects experienced from such habits.  SNAP recipients should identify with the model and realize that they too are susceptible to experiencing negative health consequences as a result of their excessive spending on junk food.  A weakness in this intervention is the inability to effectively address severe health consequences in advertising campaigns with limited space and time to address the severity of negative health consequences. However, familiarity with the health problems may encourage behavior change regardless of the ability to express severity.  The repeated exposure to the advertisements promoting the benefits of purchasing healthy foods will cause a person to purchase healthy foods in order to induce those benefits (D'Souza 1995, Edberg 2007). The barrier to accessing healthy foods must be removed by a campaign other than advertising.  The portion of the intervention that brings healthy foods to the center of low-income neighborhoods where high percentages of SNAP recipients live will remove a barrier to achieving positive health outcomes. The advertisement will function to cause people to see that there are negative health consequences associated with eating unhealthy food, so this barrier to health is addressed but will not be overcome without healthy food availability.  The unveiling of a healthy food market will be a cue to action for people to begin purchasing and consuming healthy foods. Self-efficacy will drive a person to take steps towards healthy eating by purchasing healthy foods.  The food purchasing behavior of SNAP recipients will be improved. This campaign is likely to reach non-SNAP recipients in the same community. Therefore, greater health benefits among larger populations can be achieved.
Minimizing Psychological Reactants
As demonstrated, the distribution of bowls and plates will likely cause SNAP recipients to refuse to engage in portion control practices due to the effects of psychological reactants.  In the intervention proposed, telling people how much food to consume is eliminated.  Instead, the intervention seeks to exemplify the positive health effects that are a result of healthy eating.  To avoid the negative health effects of psychological reactants, the intervention promotes the freedom to choose to be healthy instead of telling SNAP recipients the steps they must take in order to be healthy (Brehm 1966).
To avoid threats to freedom, the proposed intervention omits any mention of portion control or specifically what healthy foods must be consumed.  SNAP recipients perceived familiarity with the model removes the threat that the government is telling SNAP recipients how to eat. This further minimizes reactants (Burgoon 2002).
Additionally, the placement of a place to buy healthy food in low-income neighborhoods maximizes familiarity and minimizes threats to time and freedom.  Feeling pressured by SNAP interventionists to travel to unfamiliar neighborhoods to buy groceries may be perceived as threatening (Laurin 2012).  Being told where to travel to spend SNAP funds due to the lack of accessible healthy food markets a reasonable distance from a SNAP recipient’s neighborhood may encourage SNAP recipients to shop more often at their local convenience store, where junk food is readily available (Laurin 2012). The intervention proposed minimizes the threat to physical travel and physical freedoms by placing a healthy food market within reasonable travel distance (Brehm 1966, Burgoon 2002, Laurin 2012).

Social Learning Theory: Using Models to Promote and Sustain Healthy Food Purchasing Habits
Using social learning theory to develop an intervention for SNAP recipients must begin by competing with the social learning theory methods employed by junk food companies to encourage the purchase of healthy foods (Shaffer 2006).  Studies show that repeated exposure to product advertisements increases the market share of products. Additionally, market shares for products also increase when an advertisement is repeated more often than a competing product advertisement (D'Souza 1995).  Therefore, as many advertisements that can be afforded should be created and directed to SNAP recipients.  Advertisements that promote healthy food purchases must have more advertising space in order to compete with junk food ads for increased food purchasing shares.
Encouraging healthy food purchases through modeling and inducing a sense of identification will lead to the memory, performance, and positive reinforcement of healthy food purchasing (DeFleur 1989). Investing in purchasing media space to advertise healthy foods and compete with junk food advertising is necessary (D'Souza 1995). For social learning theory to be effective in promoting healthy food purchasing behaviors, the advertisement must use a model with which SNAP recipients can identify (DeFleur 1989). The model eating healthy foods must represent the majority demographic of the area in which an advertisement is placed. If the intervention seeks to target non-elderly females, the effects will be maximized if a non-elderly female model who also represents the sociocultural and racial majority in a community is advertised.  The model should be attractive with respect to the major cultural beliefs of the targeted population and have a positive attitude to be effective (Bansal 2005).  If SNAP recipients identify with the model and perceive her health benefits as desirable, then if they will be likely to purchase healthy foods. The positive health benefits will reinforce the probability that a SNAP recipient will continue healthy food purchasing behaviors (DeFleur 1989).
Enhancing the popularity or the likeability of the person delivering a healthy eating message helps the target population identify with the intervention messenger.  This is why junk food companies sometimes seek out actual people to serve as advertising models in addition to print and digital media sources (Shaffer 2006).  Employing similar tactics to encourage healthy eating among SNAP recipients will be useful because of social learning theory.  At the new healthy food market, it would be beneficial to have respected members of the community present at a table that distributes free samples of dishes prepared with ingredients that can all be found within the healthy food market.  Church group members, members of public school committees, and other well-known citizens concerned with the health and welfare of the community would be good models to distribute samples of healthy foods prepared with previously unavailable healthy ingredients.  If the model citizens are perceived to emulate healthy eating habits, SNAP recipients present at the healthy food market may choose to purchase the healthy ingredients that their role models utilized.  Once the health benefits and quality of food are recognized, purchasing healthy foods will become a habit (DeFleur 1989).
The negative health outcomes associated with poor diets are not unique to SNAP recipients.  However, the unavailability of healthy food options in low-income communities is a barrier to healthy food purchases for SNAP recipients. Previous interventions failed to increase the likelihood that SNAP recipients would purchase healthy foods instead of junk food. Using the health belief model, psychological reactants theory, and social learning theory, the new intervention model will be a greater influence on SNAP recipients purchasing behaviors as long as healthy foods become more readily available. The intervention is targeted at SNAP recipients, specifically non-elderly females, but the advertising campaign and availability of healthy food may induce positive health benefits for all people residing in low-income areas.  Addressing the health belief model, psychological reactants theory, and social learning theories will cause the proposed intervention to achieve its goal.  Effectively promoting healthy food purchasing behaviors will reduce the negative health outcomes among SNAP participants.

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