June 6, 2016
Desk Officer for Agriculture
Office of Information and Regulatory Affairs
Office of Management and Budget (OMB)
Departmental Clearance Office, USDA, OCIO
Mail Stop 7602, Washington, DC 20250–7602
Re: Evaluation of Food Insecurity Nutrition Incentives (FINI); OMB Control Number: 0584–NEW
Dear Sir or Madam,
The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Office of Management and Budget (OMB) regarding the information collection by the Food and Nutrition Service (FNS) of the United States Department of Agriculture (USDA) on the "Evaluation of Food Insecurity Nutrition Incentives (FINI)." Representing over 90,000 registered dietitian nutritionists (RDNs),1 nutrition dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation’s health through food and nutrition across the lifecycle and work to ensure that all Americans have access to a healthy, safe food supply by leading efforts to reduce food deserts and food swamps and by delivering effective nutrition education programs.
The Academy supports initiatives and programs that effectuate the purpose of the Food and Nutrition Act (the "Act") "to provide for improved levels of nutrition among low-income households."2 Notably, although "SNAP is working to reduce food insecurity"3 dietary quality remains an ongoing and critical concern and participants experience shortfalls in consumption of recommended amounts of fruits and vegetables.4
A. SNAP, Food Insecurity, and Dietary Quality
It is the position of the Academy of Nutrition and Dietetics that systematic and sustained action is needed to achieve food and nutrition security for all in the United States. To eliminate food insecurity, a variety of interventions are needed, including adequate funding for and increased utilization of food and nutrition assistance programs, inclusion of food and nutrition education in such programs, and innovative programs that promote and support individual and household economic self-sufficiency.5 The Academy knows that adequate funding for and increased use of food and nutrition assistance programs, particularly those already incorporating nutrition education, is particularly important to improve the dietary outcomes related to food insecurity. For too many Americans, SNAP provides—rather than merely supplements—their caloric intake, so enhanced, effective incentive programs and concomitant education that help maximize the healthiness of food choices is critical. Food insecurity, however, is only one problem SNAP aims to ameliorate. For too long, our country has failed to sufficiently focus on SNAP's original purpose "to provide for improved levels of nutrition among low-income households."6
SNAP is the nation's largest federal domestic nutrition assistance program, and provides 45.4 million Americans of all ages, races/ethnicities, and geographic locations with critical supports to purchase food for themselves and their families. In 2015, the average SNAP client received a monthly benefit of $126.39, and the average SNAP household received $256.11 monthly. SNAP benefits have proven to be one of the most important safety nets across the United States. Almost 90% of SNAP households live below the poverty line, and about 40% of SNAP households have incomes less than half of the poverty line. At the same time, SNAP reduces the likelihood of being food insecure by 30% and being very food insecure by 20%. Yet while SNAP helps to reduce hunger and food insecurity, research has found that SNAP participants consumed fewer fruits, vegetables and whole grains, and more added sugars than those with higher incomes and those with low incomes but not participating in SNAP.7
SNAP is thus a critically important tool for addressing the crisis of food insecurity and its sequelae among one of the most vulnerable populations in America. An effective and efficient SNAP program is essential to fulfilling mandates to improve dietary quality, reduce the epidemic of overweight and obesity and enhance overall health in this underserved population. The Academy acknowledges the importance of improving food security, which is independently associated with both important nutrition and non-nutrition outcomes, including:
- inadequate intake of key nutrients; poor physical and mental health in adults and depression in women;
- overweight and weight gain (especially among women from marginal and low food security households);
- adverse health outcomes for infants and toddlers;
- behavior problems in preschool-aged children;
- lower educational achievement in kindergarteners; and
- depressive disorder and suicidal symptoms in adolescents.8
As average food security improves, improving dietary quality among SNAP participants becomes an increasing priority, given the correlation of poverty and lack of food access to higher incidence of obesity and chronic disease, including type 2 diabetes, cardiovascular disease, hypertension, chronic renal failure and other poor health outcomes.9 Risk factors for these conditions are exemplified by dietary shortfalls (e.g., fewer fruits, vegetables and whole grains) and excesses (e.g., more added sugars, especially in the form of sugar-sweetened beverages).10 Other research shows deficits in seafood and plant protein intake as well.11 Notably, some research indicates that SNAP participants are often aware of these shortfalls and use Nutrition Facts labels and front of package labeling more often than higher-income shoppers to make purchasing decisions that could improve their diets. The Academy is committed to improving the nutritional intake of all Americans, and supports efforts to align SNAP with the Dietary Guidelines for Americans (DGA) and SNAP's statutory purposes.
B. Food Insecurity Incentive Programs
The Food Insecurity Nutrition Incentive (FINI) Grant program was authorized in the 2014 Farm Bill as a way to address these diet shortfalls, and investigate pilot programs that will achieve the legislative goals of "increasing fruit and vegetable purchases" and "improving the nutrition and health status" of participating households.13 Funded pilots will test community-based strategies that utilize incentives at the point of purchase to increase fruit and vegetable purchases by SNAP participants.14
1. Barriers to Increasing Fruit and Vegetable Consumption
The Double Up Foods Bucks Program (DUFB) and other small-scale incentive programs present many unique opportunities to further the field of nutrition incentive research and build the case for incentives as a vehicle for behavior change in low-income individuals. Much research has been conducted to assess the barriers to increasing fruit and vegetable consumption in this population, with price, access, and convenience at the top of the list. SNAP shoppers are motivated by desires for improved taste, quality, and nutrition - much like higher-income shoppers, but must also balance the needs for convenience, storability, economy, and finding foods the whole family will eat. Because of this, the majority of SNAP benefits go towards meats and proteins – when SNAP participants should be spending most of those dollars on fruits and vegetables, and less on meats, beverages, sweets, and packaged foods.
The problem of access to well-stocked stores is compounded by several factors: 1) the inadequate transportation resources and options many low-income people face; 2) the increased weight and bulk of many healthy foods (e.g., produce) compared to processed and packaged items substantially increases the difficulty of transport under any circumstance (except for perhaps, a private vehicle); 3) the time constraints they face (even while the program’s benefit allotment assumes unreasonable amounts of time to purchase and prepare food); 4) the age, disabilities and other mobility limitations of many beneficiaries; and 5) the lack of cooking resources many face.15
SNAP shoppers also travel less frequently to the store for food than other shoppers, and must often rely on transportation besides their own, which also changes what foods this population will purchase. Interestingly, research has found that price far outweighs access when determining purchases of fruits and vegetables – SNAP customers will travel just as far as higher-income shoppers to go food shopping, but are very sensitive to price changes. Though food insecurity is a challenge in all settings, Dean (2011) found that rural residents who need to travel further to purchase food, report lower consumption of fruits and vegetables than urban residents- and a poorer food retail environment overall.16 In another study, Rahkovsky and Snyder (2015) found that low-income, low-access consumers had only moderately poorer food purchases compared to other consumers. When separating low-income from low-access, low-income was more strongly associated with unhealthful food purchases rather than access. Consumers who traveled further from their homes to purchase food still ended up purchasing less healthful options.17
Though there are similarities in where low-income and higher-income individuals shop, how they get there differs. SNAP participants and food-insecure households are more likely to use someone else's car, walk, bike, or use public transport to do their shopping, and therefore make trips to the store less frequently than higher-income, food-secure households. This is a key difference with implications for the structure and messaging of incentive programs – most notably, that these consumers may have other constraints that bar them from making frequent trips to purchase perishable items, like fresh fruits and vegetables.18 The reasons given by SNAP participants for not shopping at farmers markets are also familiar, with the most predominant reason being the convenience of buying all groceries at one store. Other factors related to convenience were mentioned as well, including inconvenient days or hours of operation of the market. Participants in this study were also more likely to shop at the farmers market if they were aware of the incentives available to them – demonstrating that although convenience is a powerful barrier, price supports can be a useful motivator.19>
For SNAP participants to eat more fruits and vegetables, they must purchase more – but shifting purchasing behaviors is a complicated task. Fish, Brown, and Quandt (2015) found that for low income shoppers, produce purchases are mainly motivated by cost and family preferences, though some differences among ethnic groups exist. African American shoppers purchased more canned or frozen fruits and vegetables due to convenience, and because they felt they were quicker and easier to prepare when cooking skills were lacking. Conversely, Latinas preferred fresh fruits and vegetables and felt comfortable preparing these foods. Both ethnic groups had reservations about shopping at farmers markets, for reasons including inconvenient hours, difficulty traveling to the market, and food safety concerns (mainly present among African American shoppers). Participants in the study reported shopping for groceries once every one to two weeks, and purchasing other non-food groceries during the same trip to save on time and transportation costs. Other barriers to purchasing more fresh fruits and vegetables included concerns about spoilage, waste if the family doesn't eat it, and time needed to prepare the food.20
The Academy recommends that FNS recognize that non-traditional venues such as farmers markets, community supported agriculture, mobile venues such as produce trucks, or specialty meat stores are a key part of the healthy food retail landscape and that they are organized in fundamentally different ways than traditional stores. Farmers markets and farm stands can be established more quickly and at lower cost than building new food stores in these neighborhoods, and much of the food sold at farmers markets is very nutritious. Cost incentives allowing SNAP recipients to purchase fresh, nutritious foods have shown promise and should be encouraged. Conscientiously removing the structural barriers of the inappropriate retailer application and additional processing fees would meet FNS's goals immediately, serve the shopping preferences of SNAP consumers, improve the public perception of the program, and would not jeopardize program integrity. Most farmers markets are required to pay a transaction fee for SNAP sales because their states do not require EBT processing companies to provide service to food retailers that use wireless systems. The Academy encourages FNS to work with states to allow SNAP recipients to utilize new Point-of-Sale technologies that do not include up-front costs or significant monthly fees (similar to technologies such as Square credit card readers) to increase efficiencies.
2. Factors to Consider from Evaluation of Existing Incentive Programs
Certain factors may be valuable in increasing the success of an incentive program. For example, the Shop N Save (SNS) program operates at one particular farmers market located at a federally qualified health center (FQHC) in rural South Carolina where total food assistance revenue doubled after the implementation of SNS, and SNS matching coupons accounted for 16% of all sales in 2012. In fact, four times more SNAP dollars were used at the market after SNS was implemented. The researchers cite some interesting factors that may have contributed to the program’s success; the market's location within a FQHC and the use of immediate, tangible rewards.21 The FQHC in the study provides healthcare to over 25,000 patients, many of whom are on federal assistance programs, and is located in an area with subsidized housing, businesses, and other shopping and transit nearby. Thus, the market was located in an ideal setting for attracting SNAP customers, and given its proximity to other services, was likely more convenient for customers to get to as they ran other errands or received services at the health center.
Researchers found that Philly Food Bucks users were more likely to report increased consumption of fruits and vegetables since visiting the market and trying new fruits and vegetables than non-users. Other factors associated with these measures include receiving nutrition education at the market and walking or biking to the market. The majority (75%) of Philly Food Bucks redeemed were distributed via the SNAP model, while 25% of redemptions were distributed via community groups. SNAP sales at the farmers markets increased at a greater rate after Philly Food Bucks was introduced, and stimulated a greater than expected use of SNAP benefits – every $1 in Philly Food Bucks sales was associated with $3.75 of SNAP sales in 2010 and $2.75 in 2011 – compared to the expected ratio of $1 incentive for every $2.50 in SNAP benefits (given the bonus model of a $2 incentive for every $5 in SNAP benefits).22
We note that success of incentive programs may correlate with participants' awareness of the details and complexity of the incentive program, including understanding the quantity of the incentive, its impact on price, and which foods qualify for the incentive. Thus, outreach and promotion of the incentive program can be critical in ensuring its effectiveness.23 Education should include community-level and individualized SNAP-Education designed or provided by registered dietitian nutritionists. Education can be particularly effective when provided at grocery stores and farmers markets.24,25
The Academy strongly supports pilot programs using the DGA as a reference point for food assistance selection within SNAP with incentives for recipients' participation. SNAP-Education can also enhance education programs to encourage use of fresh fruits and vegetables in multiple simple recipes with few ingredients (as has successfully been done in the new www.eatfresh.org website). Making this information available seasonally for local and fresh products from USDA or a derivative, such as Cooperative Extension, would additionally help nutrition education and promote healthy food purchase.
In terms of overall measurement and evaluation, FNS should also consider the following factors in addition to those noted above:
- Quasi-experimental study of program impact using control groups in each city.
- More in-depth dietary recall measures, collected over time.
- Larger sample sizes.
- Use of sales data to show economic benefit to farmers – rather than relying on surveys.
- More specific sales tracking to capture repeat customers, redemption rates, and tracking of customers between programs (farmers market and grocery store) where applicable.
- Breakdown of fruit and vegetable purchases by categories (e.g., frozen, fresh, canned) and the type and variety purchased.
- Including requirements for marketing, promotion, and education efforts that encourage SNAP participants to purchase healthy foods and beverages.
- Identification of differences among racial, ethnic, and other demographics, including differences among participants with and without children, rural v. urban populations, and participants with and without access to sufficient refrigeration and cooking resources.
- Impact of various levels of outreach and promotion.
- Impact of various types of SNAP-Education on consumer purchase behavior.
- Gathering data on how the program shifts the overall budget of SNAP participants and if any changes occur in the proportion of their budget spent on meats, beverages, sweets, fruits, and vegetables.
Further, in terms of continuing to improve future incentive programs and leverage best practices from previous initiatives and evaluative studies, the Academy makes the following additional recommendations:
- Continued revision of the grocery store reward program to maintain visibility and streamline the check-out process.
- Consideration of the shopping habits of SNAP participants and customizing both incentive programs to their needs – fewer trips to the store, potential confusion over reward process, etc.
- Focus on communication and education that supports the cost-effectiveness of fresh produce and provides participants with ideas for incorporating into their regular meal planning and shopping.
The Academy appreciates the opportunity to comment on the information collection evaluating FINI grant programs. We are happy to discuss these recommendations in greater detail in the near future. Please contact either Jeanne Blankenship at 312/-899-1730 or by email at firstname.lastname@example.org or Pepin Tuma at 202/775-8277, ext. 6001 or by email at email@example.com with any questions or requests for additional information.
Jeanne Blankenship, MS, RDN
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics
Pepin Andrew Tuma, Esq.
Government & Regulatory Affairs
Academy of Nutrition and Dietetics
1 The Academy approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.
2 7 U.S.C. § 2011 (2015).
3 Godoy M. How America's Wealth Gap Shows Up On Our Dinner Plates. National Public Radio: The Salt citing Andreyeva, T, et al. Dietary Quality of Americans by Supplemental Nutrition Assistance Program Participation Status. Am J Prev Med. 2015 Oct;49(4):594-604.
4 Condon, E., Drilea, S., Jowers, K., Lichtenstein, C., Mabli, J., Madden, E., & Niland, K. (2015). Diet Quality of American by SNAP Participation Status: Data from the National Health and Nutrition Examination Survey, 2007-2010. Rockville: Prepared by Walter R. McDonald & Associates, Inc. and Mathematica Policy Research for the Food and Nutrition Service.
5 Holben DH. Position of the American Dietetic Association: Food insecurity in the United States. J Am Diet Assoc. 2010; 110: 1368-1377.
6 Food Stamp Act of 1964, Pub. L. No. 88-525, 78 Stat. 703 (1964).
7 Godoy M. How America's Wealth Gap Shows Up On Our Dinner Plates. National Public Radio: The Salt citing Andreyeva, T, et al. Dietary Quality of Americans by Supplemental Nutrition Assistance Program Participation Status. Am J Prev Med. 2015 Oct;49(4):594-604.
8 Stang J, Bayerl CT. Position of the American Dietetic Association: child and adolescent nutrition assistance programs. J Am Diet Assoc. 2010;110(5):791-99.
9 Seligman HK, Laraia BA, Kushel MB. Food insecurity is associated with chronic disease among low-income NHANES participants. J Nutr. 2010;140(2):304-10.
10 Godoy M. How America's Wealth Gap Shows Up On Our Dinner Plates. National Public Radio: The Salt citing Andreyeva, T, et al. Dietary Quality of Americans by Supplemental Nutrition Assistance Program Participation Status. Am J Prev Med. 2015 Oct;49(4):594-604.
11 Nguyen BT, et al. The Supplemental Nutrition Assistance Program and dietary quality among US adults: findings from a nationally representative survey. Mayo Clin Proc. 2014 Sep;89(9):1211-9.
12 Mancino, L., & Guthrie, J. (2014, November 3). SNAP Households Must Balance Multiple Priorities to Achieve a Healthful Diet. Accessed June 3, 2016.
13 Food, Conservation, and Energy Act of 2008, § 4405(b)(4)(A).
14 National Institute of Food and Agriculture. (n.d.). Food Insecurity Nutrition Incentive (FINI) Grant Program. Accessed June 3, 2016.
15 Gregory, C., Ver Ploeg, M., Andrews, M., & Coleman-Jensen, A. (2013). Supplemental Nutrition Assistance Program (SNAP) Participation Leads to Modest Changes in Diet Quality. Washington DC: Economic Research Service, USDA.
16 Dean WR, Sharkey JR. Rural and urban differences in the associations between characteristics of the community food environment and fruit and vegetable intake. J Nutr Educ Behav. 2011;43(6):426-33.
17 Rahkovsky, I., & Snyder, S. (2015). Food Choices and Store Proximity. Washington: Economic Research Service, United States Department of Agriculture.
18 Morrison, R. M., & Mancino, L. (2015, August 3). Most U.S. Households Do Their Main Grocery Shopping at Supermarkets and Supercenters Regardless of Income. Available from Amber Waves, United States Department of Agriculture. Accessed June 3, 2016.
19 Karakus, M., Milfort, R., MacAllum, K., & Hao, H. (2014). Nutrition Assistance in Farmers Markets: Understanding the Shopping Patterns of SNAP Participants. Washington: Prepared by Westat for the U.S. Department of Agriculture, Food and Nutrition Service.
20 Fish CA, Brown JR, Quandt SA. African American and Latino low income families' food shopping behaviors: promoting fruit and vegetable consumption and use of alternative healthy food options. J Immigr Minor Health. 2015;17(2):498-505.
21 Freedman DA, Mattison-faye A, Alia K, Guest MA, Hébert JR. Comparing farmers' market revenue trends before and after the implementation of a monetary incentive for recipients of food assistance. Prev Chronic Dis. 2014;11:E87.
22 Young CR, Aquilante JL, Solomon S, et al. Improving fruit and vegetable consumption among low-income customers at farmers markets: Philly Food Bucks, Philadelphia, Pennsylvania, 2011. Prev Chronic Dis. 2013;10:E166.
23 See, e.g., Lindsay S, Lambert J, Penn T, et al. Monetary matched incentives to encourage the purchase of fresh fruits and vegetables at farmers markets in underserved communities. Prev Chronic Dis. 2013;10:E188 (noting that the City Heights Farmers Market Fresh Fund program in San Diego County conducted outreach and promotion within the community for 22 weeks and included a media campaign, community organizations, and informational flyers being sent to homes in neighborhoods near the farmers markets).
24 Young CR, Aquilante JL, Solomon S, et al. Improving fruit and vegetable consumption among low-income customers at farmers markets: Philly Food Bucks, Philadelphia, Pennsylvania, 2011. Prev Chronic Dis. 2013;10:E166.
25 Fair Food Network. (2015). Double Up Food Bucks Grocery Project: Report on 2014 Program Season.