By Susan Blumenthal, M.D. and Sara Kiani
A US Department of Agriculture report published in 2016 analyzed point of sale transaction data gathered from supermarkets, grocery markets, and combination food and drug stores in 2011. A startling finding: across all households, more money was spent on soft drinks than any other food item. Additionally, sugar-sweetened beverages, which include fruit juices, energy drinks, sweetened tea, and soft drinks, accounted for over 7% of Americans’ grocery budgets. This is of considerable concern since high levels of sugar-sweetened beverage consumption has been found to be a major risk factor for the obesity epidemic in the United States. Experts report that calories consumed in liquid form do not trigger the same sensation of fullness; therefore, additional caloric intake by people tends to occur. These sugar-sweetened beverages are the leading source of added sugar in the American diet, despite the fact that consuming large amounts of these drinks is associated with health damaging consequences including an increased risk for obesity, type 2 diabetes, heart disease, kidney diseases, non-alcoholic liver disease, tooth decay, and gout. For these reasons, more information is needed about the purchasing patterns of Americans to develop and implement effective interventions that can reduce consumption of sugar-sweetened beverages including soft drinks in the United States.
The USDA report compared the food purchasing patterns of SNAP (Supplemental Nutrition Assistance Program) households to those of non-SNAP households from all income levels. SNAP provides benefits to U.S. households experiencing food insecurity, meaning they have limited or uncertain access to adequate foods. SNAP benefits can be used to purchase food at grocery stores, convenience stores, and some farmers' markets and co-op food programs. Each month SNAP, a $73 billion program, provides nutrition assistance to over 41 million eligible, low-income Americans. About two-thirds of SNAP participants are children, elderly, or disabled people. On average, SNAP benefits account for over 60% of a SNAP household’s food-at-home expenditures, meaning this program plays a crucial role in providing nutrition for millions of Americans. A recent study found that the program helps families buy more nutritious foods than they otherwise could afford. According to these researchers' model, a $30 increase in monthly SNAP benefits would increase participants’ consumption of nutritious foods, such as vegetables and healthy proteins, while reducing food insecurity and consumption of fast food. SNAP is a vital food assistance program that is important to the health of millions of Americans. Studies have shown that participation in the program can improve infant birth outcomes and has long-term benefits for children as well. A 2012 report revealed that children who receive SNAP benefits were less likely to be underweight or have developmental delays as compared to children who are eligible but not enrolled in SNAP. Despite significant program benefits, high levels of sugar-sweetened beverage purchasing still occurs in SNAP households, as it does across all income levels in the United States.
The USDA 2016 report found that across all households, more money was spent on soft drinks than any other food item. In SNAP households, “sugar-sweetened beverages” was the number two category of food purchased, after meat, poultry, and seafood, representing 9.3% of food expenditures. For non-SNAP households, “sugar-sweetened beverages” was the number five category of food purchased, with 7.1% of food expenditures spent on these products. In both groups, sugar-sweetened beverages ranked in the top 5 in a list of 30 food categories, indicating high levels of food expenditures on these products. Additionally, both household groups were equally likely to purchase salty snacks (about 3% of food purchases), cookies (about 1 percent), and ice cream, ice milk, and sherbet (about 1 percent). The report revealed that almost one-fifth of all food dollars were spent on products purchased could be broadly classified as foods with minimal nutritional value.
This was one of the first studies examining the food purchasing patterns of both SNAP and non-SNAP participants. In the study, SNAP participants were identified by their use of SNAP benefits at point of checkout. The report states that “differences in the expenditure patterns of SNAP and non-SNAP households were relatively limited”. The top ten summary categories for food and beverage purchases and top 7 commodities by expenditure for the two groups studied were the same, although they were ranked in slightly different orders. Additionally, for both groups the top five summary categories comprised almost 50% of food expenditures. The study did not examine the income of non-SNAP participants, but a recent review also found few differences in the purchasing patterns of sugar-sweetened beverages between SNAP and eligible non-SNAP households. Unfortunately, for both SNAP and non-SNAP households, research findings report a high level of spending on sugar-sweetened beverages and other unhealthy foods.
High levels of soft-drink purchasing and consumption are of significant concern because these drinks provide calories with limited nutritional value. Considering the average can of sugar-sweetened soda or fruit punch provides about 150 calories, drinking one can a day without cutting back on calories elsewhere would lead to about a 5 pound weight gain over a year. In 2016, sugar-sweetened beverages were a major contributor to the obesity epidemic, which accounts for an estimated $150 billion in direct medical costs alone. Studies show that those who consume these beverages tend to have an overall lower dietary quality. Given that an estimated 70% of American adults are either overweight or obese and that this condition is linked to high medical and economic costs, it is important to reverse this health damaging trend in food purchasing.
New research has revealed promising findings. In the U.S., there has been a decrease in sugar-sweetened beverage consumption between 2003 and 2014. In 2003, 79.7 percent of children and 61.5 percent of adults drank a sugar-sweetened beverage on any given day, and by 2014 these percentages had decreased to 60.7 percent of children and 50 percent of adults. Unfortunately, these numbers are still quite high, particularly among minority populations who have higher rates of obesity in the United States.
Addressing the Issue
SNAP provides a unique opportunity to address high levels of sugar-sweetened beverage purchasing. Experts propose two interventions that could potentially decrease the amount of SNAP spending on these products. The first strategy proposed by some experts is to consider restricting the purchase of sugar-sweetened beverages in SNAP. While this proposal is controversial, some states and cities have requested permission to adopt such a policy. However, the USDA has denied all requests submitted since 2004. Those who argue against restricting the purchase of these beverages in SNAP suggest it would increase administrative costs to the USDA and retailers, increase stigma faced by program recipients, discriminate against beneficiaries, and fail to change consumption patterns. About 70-80% of SNAP participants supplement their federal assistance benefits with their own cash. Some experts suggest that restricting the purchase of sugar-sweetened beverages from SNAP eligibility would cause people to use their out of pocket funds to purchase these products.
The second proposed intervention is to provide incentives for healthy eating in SNAP. The Farm Bill that funds SNAP set aside $20 million in 2008 and $100 million in 2014 for grants that support projects for purchasing fruits and vegetables, including the The Healthy Incentives Pilot in Massachusetts. This program provided a 30 cent rebate for every dollar spent on select fruits and vegetables. As a result, the state reported a 25% increase in the consumption of the targeted fruits and vegetables from 2011 to 2012. Yet, a study published in 2014 that modeled the expected effects of these two proposed interventions found that restricting purchase of sugar-sweetened beverages in SNAP would likely have a greater effect on reducing obesity prevalence and Type 2 diabetes incidence, particularly among people ages 18 to 65 and for some racial and ethnic minority populations. Given these findings, some experts have suggested that the USDA support pilot studies to examine the health and consumption effects of restricting purchase of sugar-sweetened beverages with SNAP dollars. In the meantime, states should continue to expand incentives for purchase of healthy foods, a strategy that has already been proven to be effective.
While recent research suggests that people in the United States are consuming fewer sugar-sweetened beverages than in previous years, nonetheless, across all households, more money is being spent on soft drinks than any other food item. This means that the U.S. still has a long way to go to significantly reduce consumption of these beverages. The high level of consumption of sugar-sweetened beverages including soft drinks is a significant contributor to the obesity epidemic, which has an enormous health and economic impact in the United States. Innovative strategies are needed to reduce the high level of sugar-sweetened beverage consumption in order to achieve a healthier future for Americans now and in the years ahead.
Rear Admiral Susan Blumenthal, M.D., M.P.A. (ret.) is the Public Health Editor of the Huffington Post. She is a Senior Fellow in Health Policy at New America and a Clinical Professor at Georgetown University School of Medicine. She directs the SNAP to Health Initiative and website at New America and recently chaired a WIC Digital Health Summit in collaboration with MIT and the Harvard T.H. Chan School of Public Health. Dr. Blumenthal served for more than 20 years in senior health leadership positions in the Federal government in the Administrations of four U.S. Presidents including as Assistant Surgeon General of the United States, the first Deputy Assistant Secretary of Women’s Health, and as Senior Global Health Advisor in the U.S. Department of Health and Human Services. She also served as a White House Advisor on health. Prior to these positions, Dr. Blumenthal served as Chief of the Behavioral Medicine and Basic Prevention Research Branch and Chair of the Health and Behavior Coordinating Committee at the National Institutes of Health (NIH). She has chaired numerous national and global commissions and conferences and is the author of many scientific publications. Admiral Blumenthal has received numerous awards including honorary doctorates and has been decorated with the highest medals of the U.S. Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide. Named by the New York Times, the National Library of Medicine and the Medical Herald as one of the most influential women in medicine, Dr. Blumenthal was named the Health Leader of the Year by the Commissioned Officers Association and as a Rock Star of Science by the Geoffrey Beene Foundation. She is a recipient of the Rosalind Franklin Centennial Life in Discovery Award.
Sara Kiani graduated from Yale University in 2017 with a Bachelor’s degree in Psychology and Spanish. As a Yale Global Health Scholar, she conducted independent research with Universidad Nacional Autónoma de Nicaragua - León on the impact of mode of childbirth and other factors on breastfeeding measures including duration and exclusivity. She also worked at IMPACTA in Lima, Peru studying factors that affect HIV and TB treatment adherence. Ms. Kiani previously worked as a Research Assistant in the Marsh Lab at Duke University, studying how learning, memory and personal narratives affect PTSD outcomes. Sara currently serves as a Health Policy Fellow at New America in Washington D.C. and will attend Icahn School of Medicine at Mount Sinai in 2018.