ed.: With the Thanksgiving and The Robert H. Levi Public Forum: Bioethics, Healthy Eating and Obesity Prevention Policies: November 28, 2012 4:30pm-6:15pm, Chevy Chase Auditorium, Johns Hopkins Hospital both imminent, we’ve pulled the following post from The Bioethics Bulletin Archives (Originally posted November 18, 2010)
Soda exclusion pairs well with public health mission, but risks stigmatizing beneficiaries
Greenwall fellow Anne Barnhill offers some food for thought before Thanksgiving
As Americans sit down to Thanksgiving dinner this year, a record number will be relying on food stamps to put food on the table. One in eight Americans now use food stamps—a total of more than 41 million people. The food stamp program, which was renamed SNAP (Supplemental Nutrition Assistance Program) in 2008, gives qualifying families an average of $227 each month (but up to $668, depending on family size and income), which they can use at participating stores to buy any food item.
Well, almost any food item: SNAP assistance can’t be used to purchase hot food and prepared food (e.g. a sandwich from a deli), but only food for home consumption. SNAP assistance also can’t be used to purchase alcohol.
Some public health officials have proposed an additional restriction: Food stamp recipients shouldn’t be able to purchase soda and other sweetened beverages (such as fruit drinks, sports drinks, and sweetened iced tea) with food stamps. New York City recently proposed excluding sweetened beverages from food stamps as part of a demonstration project in New York City—essentially, a trial run of a sweetened beverage exclusion. Minnesota previously proposed excluding soft drinks and candy from food stamps, but failed to get the necessary approval from the U.S. Department of Agriculture, which administers SNAP.
The USDA should approve New York City’s proposed demonstration project. The best reason to exclude sweetened beverages from SNAP is the potential public health benefit. Sweetened beverages are the single largest source of calories in Americans’ diet—9 percent of total calories—and consumption of sweetened beverages increases the risk of obesity and diabetes. Sweetened beverages appear to be a significant part of the purchases of SNAP recipients: According to a recentstudy of one large supermarket chain, 6.9 percent of the grocery bill of SNAP users was carbonated soft drinks, compared to 4.38 percent for the average shopper. It’s estimated that the federal government will spend $4 billion on soft drinks for SNAP recipients in 2011.
A few more facts:
~ Nearly half of the sugar consumed by Americans comes from sweetened beverages.
~ Each additional sweetened beverage per day increases a child’s odds of becoming obese by 60 percent.
~ The risk of developing diabetes was 83 percent higher among women who consumed one or more sweetened beverages a day.
Funding sweetened beverages is contrary to the aims of the food stamp program—alleviating hunger and improving the nutrition and health of low-income people. Sweetened beverages don’t alleviate hunger because they aren’t satiating, and they have little or no nutritional value. Sweetened beverages simply make the diet of SNAP recipients worse by adding excess calories and sugar, which contributes to overweight/obesity, diabetes, and other chronic diseases. Low-income people have higher rates of obesity, diabetes and other chronic diseases—such as heart disease—than higher income people. And funding sweetened beverages consumption through food stamps exacerbates these health disparities, rather than remedying them.
Would a soda ban succeed, stigmatize?
In the other corner, opponents of the sweetened beverage exclusion raise doubts about it. Will the exclusion succeed in reducing consumption? Won’t it be embarrassing to SNAP recipients, and deter them from using food stamps? Isn’t it better to offer food stamp recipients incentives to eat healthy food, rather than restricting unhealthy food purchases?
As to whether the exclusion will succeed in reducing consumption: Many SNAP recipients use both food stamps and other sources of income to buy food, and they are expected to spend 30 percent of their income on food—if they have any income. If SNAP assistance can’t be used to purchase sweetened beverages, recipients might nonetheless buy them using their other sources of income. The (in)effectiveness of the sweetened beverage exclusion is a legitimate concern—but not a legitimate reason to reject a trial run. Whether the ban on sweetened beverages would be effective is precisely the kind of question that must be answered by demonstration projects, not by armchair speculation.
A second concern is that the sweetened beverage exclusion will be embarrassing and stigmatizing to SNAP recipients. Even if there’s an information campaign to educate SNAP recipients about the new exclusion, some recipients won’t be informed and will attempt to purchase sweetened beverages with their EBT cards (rather than paper food stamps, recipients now receive plastic Electronic Benefits Transfer cards, much like debit cards). They’ll be told at the checkout that they can’t purchase sweetened beverages, which might be embarrassing, and might make them feel singled out and stigmatized as SNAP recipients. Being stigmatized is harmful in and of itself; and the stigma associated with food stamps is a reason cited by eligible people for not using food stamps.
But would new exclusions be embarrassing and stigmatizing to a significant number of SNAP recipients? Or could an aggressive information campaign alert most SNAP recipients to the new exclusion? Will a significant number of those SNAP recipients who do feel embarrassed and stigmatized be deterred from using their benefits again as a result? Will excluding sweetened beverages from food stamps cause an appreciable increase in the social stigma associated with SNAP use? These are issues that can only be assessed through a pilot study or demonstration project.
A third objection to the sweetened beverage exclusion is that incentives to eat healthy foods are a better approach than restrictions on unhealthy food. The carrot is better than the stick, in other words. An example of an incentive program is New York City’s Health Bucks program: For every $5 of foods stamps that recipients spend at farmers’ markets, they receive a $2 coupon to use at farmers’ markets. Financial incentive has been shown to increase consumption of healthy foods—but hasn’t been shown to decrease the consumption of unhealthy foods, which is also essential to improving health. And even if incentives to eat healthy food did cause people to eat less unhealthy food, such incentive programs cost money. In this fiscal climate and political climate, it’s not realistic that incentive programs will be extended to the 41 million people who receive SNAP assistance. Excluding sweetened beverages is the more feasible approach.
Opponents of excluding sweetened beverages from SNAP raise legitimate concerns. It is uncertain whether the exclusion would work, and whether it would have negative impacts on SNAP recipients. But this is exactly why demonstrations projects that implement the exclusion and examine its effects, such as the one proposed by New York City, are in order.
~ Anne Barnhill, M.A., Ph.D., is a Greenwall Fellow at the Johns Hopkins Berman Institute of Bioethics. One of her main intellectual interests is figuring out when and why it’s ethical to restrict people’s choices and autonomy.
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