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Original Investigation |

Effects of Subsidies and Prohibitions on Nutrition in a Food Benefit Program A Randomized Clinical Trial ONLINE FIRST

Lisa Harnack, DrPH1; J. Michael Oakes, PhD1; Brian Elbel, PhD2; Timothy Beatty, PhD3; Sarah Rydell, MPH1; Simone French, PhD1
[+] Author Affiliations
1Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis
2Department of Population Health, School of Medicine and Wagner School of Public Service, New York University, New York
3Agricultural and Resource Economics, University of California-Davis, Davis
JAMA Intern Med. Published online September 19, 2016. doi:10.1001/jamainternmed.2016.5633
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Importance  Strategies to improve the nutritional status of those participating in the Supplemental Nutrition Assistance Program (SNAP) are of interest to policymakers.

Objective  To evaluate whether the proposed policy of incentivizing the purchase of fruits and vegetables and prohibiting the purchase of less nutritious foods in a food benefit program improves the nutritional quality of participants’ diets.

Design, Setting, and Participants  Lower income participants (n = 279) not currently enrolled in SNAP were randomized to 1 of 4 experimental financial food benefit conditions: (1) incentive (30% financial incentive for fruits and vegetables purchased using food benefits); (2) restriction (not allowed to buy sugar sweetened beverages, sweet baked goods, or candies with food benefits); (3) incentive plus restriction (30% financial incentive on fruits and vegetables and restriction of purchase of sugar sweetened beverages, sweet baked goods, or candy with food benefits); or (4) control (no incentive or restrictions on foods purchased with food benefits). Participants in all conditions were given a study-specific debit card where funds were added every 4 weeks for a 12-week period. Outcome measures were collected at baseline and in the final 4 weeks of the experimental period.

Main Outcomes and Measures  Primary outcomes (from 24-hour dietary recalls) included intake of energy, discretionary calories, and overall diet quality.

Results  A number of favorable changes were observed in the incentive plus restriction condition that were significantly different from changes in the control condition. These included (1) reduced intake of energy (−96 kcal/d, standard error [SE], 59.9); (2) reduced intake of discretionary calories (−64 kcal/d, SE 26.3); (3) reduced intake of sugar sweetened beverages, sweet baked goods, and candies (−0.6 servings/d, SE 0.2); (4) increased intake of solid fruit (0.2 servings/d, SE 0.1); and (5) improved Healthy Eating Index score (4.1 points, SE 1.4). Fewer improvements were observed in the incentive only and restriction only arms.

Conclusions and Relevance  A food benefit program that pairs incentives for purchasing more 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 participants compared with a program that does not include incentives or restrictions.

Clinical Trial Registration  clinicaltrials.gov Identifier: NCT02643576

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Flow of Study Participants: Incentives and Restrictions in a Food Benefit Program
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