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Carrots, Sticks, or Carrot Sticks?Using Federal Food Policy to

Engineer Dietary Change

Barbara A. Laraia, PhD, MPH, RD

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In this issue of the American Journal of PreventiveMedicine, three descriptive research articles1–3 ex-plore mechanisms by which federal food policy

an influence the availability of foods and food pur-hase behaviors, in the directions emphasized in theietary Guidelines. In the article by Andreyeva andolleagues,1 the focus is on the proportion of moneyspent on beverages among Supplemental Nutrition As-sistance Program (SNAP) and non-SNAP participantsfrom a single supermarket chain. In a sample of young,low-income families that had participated in the Spe-cial Supplemental Nutrition Program for Women, In-fants, and Children (WIC) the previous year, the authorsidentifıed that the subset who were also SNAP partici-pants purchased a signifıcantly higher percentage ofsugar-sweetened beverages, compared to non-SNAPparticipants.These cross-sectional shopping behavior data stop

short of demonstrating any causal relationship betweenSNAP participation and diet quality, and previous re-search4,5 generally has not found such effects. Neverthe-less, Andreyeva et al.1 question whether federal moneyshould be spent on beverages of non-nutritive value.They conclude, somewhat provocatively, that the U.S.Department ofAgriculture (USDA) should consider con-ducting studies on limiting the use of SNAP benefıts forthe purchase of sugar-sweetened beverages.Two additional articles2,3 focus on WIC and investi-

ate whether 2009 changes in the WIC food packageight have led to increased availability and variety ofutritious foods in stores in low-income, underservedreas. Zenk et al.3 studied 329–364 (329 in 2008; 346 in2009; and 364 in 2010) WIC vendors in a seven-countyarea of northwestern Illinois, and found that over a 3-yearperiod (2008–2010) there was a small but signifıcant pos-itive change in the availability and variety of fruits andvegetables by vendor type (large and small grocery stores

From the Public Health Nutrition Program, School of Public Health, Uni-versity of California Berkeley, Berkeley, California

Address correspondence to: Barbara A. Laraia, PhD, MPH, RD, Schoolof Public Health, 207-B University Hall, #7360, University of CaliforniaBerkeley, Berkeley CA 94720-7360. E-mail: blaraia@berkeley.edu.

c0749-3797/$36.00http://dx.doi.org/10.1016/j.amepre.2012.07.018

456 Am J Prev Med 2012;43(4):456–457 © 2012 Amer

and pharmacies). In discussing these fındings, the au-thors suggested that (1) larger subsidies (incentives) and(2) a requirement that stores have a larger inventory ofthese food items to qualify as WIC vendors were stepsthat might further improve the food environment.Havens et al.2 measured the availability of specifıc

types of foods among 45 corner stores in Hartford CT.They found that after the 2009 change, WIC vendorscarried signifıcantlymore varieties of fresh fruit, a greaterproportion of lower-fatmilk, andmorewhole grain breadand brown rice than prior to the change; and that follow-ing the change, the availability of these foods was signifı-cantly greater among WIC vendors than among non-WIC vendors. Although dietary intake data were againnot available, the authors suggested that by changingavailability, WIC food package changes could lead toimproved dietary intake of fruits, vegetables, low-fat milkproducts, and whole grains. Similar to the fındings ofZenk et al.,3 the effects reported by Havens et al.2 wereodest in size. We have yet to determine to what extentmall changes in the food environment can lead to dietaryhange at the individual level.What, then, are the data from these related studies

elling us? A great effort went into changing the WICackage, to provide the means to purchase food but alsoo incentivize changes in access to food. In the end, thisay have translated only into the most modest of effects

o improve the food environment. Taken together withata suggesting a possible link between SNAP participa-ion and higher levels of sugar-sweetened beverage pur-hases, these data may emphasize that improving theood environment may take a Herculean effort. Is ourost attractive option at the moment to restrict sugar-weetened beverages from the poorest Americans?Even if there were more conclusive evidence that

NAP participation adversely affects diet quality, largerssues need to be addressed around howwe want to influ-nce Americans to eat an optimal diet. One main criti-ismof placing restrictions on SNAPbenefıts is thatwhenestrictions have been placed on SNAP in the past, par-icipation rates have declined. Restrictions on soda pur-hases would not achieve their goal if participation rateseclined or if soda purchases were replaced with pur-

hases of other energy-dense foods. Additional data

ican Journal of Preventive Medicine • Published by Elsevier Inc.

Laraia / Am J Prev Med 2012;43(4):456–457 457

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clearly are needed before the restriction of soda purchasescan be recommended.A second major criticism affecting restrictions on

SNAP benefıts is that these send a paternalistic message:that it is okay to restrict what poor Americans purchasewith federal dollars, presumably because they do notknow any better. Should not the focus be on the largerissue of how federal dollars should be spent, and restrict-ing the use of any and all federal dollars for the purchaseof sugar-sweetened beverages? If so, then this restrictionshould be placed in every food-related policy, at cafeteriasin federal buildings, and on U.S. military bases aroundthe globe. Should this discussion really be started withSNAP? Restricting the use of SNAP benefıts for the pur-chase of sugar-sweetened beverages is an ethical issuebecause SNAP is an entitlement program targeting a par-ticularly vulnerable low-income population. Decidingwhether or not to make this restriction needs to be con-sidered by a panel made up of ethicists, physicians,nurses, nutritionists, and economists.Most Americans do notmeet the dietary guidelines.6 A

priority should be to help Americans navigate the foodenvironment, with its abundance of calories, thousandsof new food products each year (mainly in the way ofprocessed, high-fat, and refıned carbohydrate foods),7

and poor access to low-cost nutritious foods.Willmakingmore carrots available or slapping a hand lead to thedietary change that is so necessary? The answer is notclear. However, as illustrated by these three articles,1–3

the way forward surely will involve continued, sober re-

search, an im

ctober 2012

the ethical and moral issues that make our federal foodpolicy challenges so compelling.

No fınancial disclosures were reported by the author of thispaper.

References1. Andreyeva T, Leudicke J, Henderson KE, Tripp AS. Grocery

store beverage choices by participants in federal food assistanceand nutrition programs. Am J Prev Med 2012;43(4):411–8.

2. Havens EK, Martin KS, Yan J, Dauser-Forrest D, Ferris AM.Federal nutrition program changes and healthy food availabil-ity. Am J Prev Med 2012;43(4):419–22.

3. Zenk SN, Odoms-Young A, Powell LM, et al. Fruit and vegeta-ble availability and selection: federal food package revisions,2009. Am J Prev Med 2012;43(4):423–8.

4. Fernandes MM. Effect of the Supplemental Nutrition Assis-tance Program (SNAP) on frequency of beverage consumptionamong youth in the United States. J Acad Nutr Diet 2012;112(8):1241–6.

5. FNS. 2000. Dietary intake and dietary attitudes among foodstamp participants and other low-income individuals. Alexan-dria VA: USDA, FNS. www.fns.usda.gov/ora/menu/published/NutritionEducation/Files/FSPDiet.pdf.

6. Kirkpatrick SI, Dodd KW, Reedy J, Krebs-Smith SM. Incomeand race/ethnicity are associated with adherence to food-baseddietary guidance among U.S. adults and children. J Acad NutrDiet 2012;112(5):624–635.e6.

7. Wells HF, Buzby JC. Dietary assessment of major trends in U.S.food consumption, 1970–2005. Economic information bulle-tin. U.S. Dept. of Agriculture. Economic Research 2008, Mar.

proved evidence base, and close attention to No. 33. www.usda.gov/factbook/.

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