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Incentives with restrictions in food benefit programs improve diet

Food benefit programs that offer incentives for purchasing fruits and vegetables along with restrictions on the purchase of less nutritious food improved the nutritional quality of participants’ diets, according to recent data published in JAMA Internal Medicine.

“There is interest in identifying ways the Supplemental Nutrition Assistance Program (SNAP) may better meet its objective to help families buy the food they need for good health because lower income families in the U.S. are disproportionately obese, with poor diet quality contributing to this health disparity,” Lisa Harnack, DrPH, of the School of Public Health at the University of Minnesota in Minneapolis, and colleagues wrote. “[However], research is lacking on the effect of pairing restrictions with incentives.”

Harnack and colleagues assessed whether the nutritional quality of 279 lower income participants’ diets were improved by participating in a food benefit program that incentivized the purchase of fruits and vegetables and restricted the purchase of less nutritional foods.

The researchers randomly allocated participants who were not currently enrolled in SNAP into one of four experimental financial food benefit conditions: Incentive, restriction, incentive plus restriction, or control. The programs that included incentives granted participants a 30% financial incentive to purchase fruits and vegetables using food benefits, and programs with restrictions prohibited participants from purchasing sugar sweetened beverages, sweet baked goods, or candy using food benefits. Those in the control group were not given any incentives or restrictions on food purchases with benefits.

All participants were given a study-specific debit card to purchase food in which funds were added every 4 weeks for a total of 12 weeks.

Energy intake, discretionary calories and overall quality of diet were measured by dietary recalls that were collected at baseline and in the final 4 weeks of the study period.

Results indicated that those in the incentive plus restriction group had multiple dietary improvements compared with the control group, including a reduction in the intake of energy (–96 kcal/d, standard error [SE], 59.9), discretionary calories (–64 kcal/d, SE 26.3), and sugar sweetened beverages, sweet baked goods, and candies (–0.6 servings/d, SE 0.2 and an increase in the intake of solid fruit (0.2 servings/d, SE 0.1). In addition, the Healthy Eating Index score of participants in the incentive plus restriction group was improved (4.1 points, SE 1.4).

The incentive only and restriction only groups had fewer favorable advances.

“These results suggest that a food benefit program that pairs financial incentives for the purchasing of fruits and vegetables with restrictions on the purchase of less nutritious foods may reduce energy intake and improve the nutritional quality of the diet of program participants in comparison with a food benefit program that does not include incentives and restrictions,” Harnack and colleagues concluded.

In an accompanying editorial, Marlene B. Schwartz, PhD, of the Rudd Center for Food Policy and Obesity at the University of Connecticut in Hartford, noted several ethical, political and legal concerns challenges that need to be addressed before updating SNAP.

“The combination approach has the potential to move the discussion forward,” she wrote. “It not only solves the problem of choosing between incentives and restrictions, but if the incentives provide a higher rate of benefits and the program is presented as an option to participants, it should also alleviate concerns about paternalism and condescension aimed at low income Americans. Because there is pilot evidence that this strategy leads to meaningful improvements to diet, arguments that these changes won’t work should be alleviated.”

“We must find a way to work together toward our common goal of having a food assistance program that ensures that all Americans have adequate amounts of healthy food,” she added. – by Alaina Tedesco

Disclosure: One author reports grants from the National Institutes of Health during the conduct of the study. None of the other authors reports any relevant financial disclosures.