Abstract
Unhealthful diet is a top contributor to chronic diseases in the United States. There are growing concerns about disparities in diet among US adults, especially for those who participate in the Supplemental Nutrition Assistance Program (SNAP), the largest federal food assistance program. It remains unclear how these disparities may have changed over time. To assess whether disparities in key food groups and nutrients according to participation and eligibility for SNAP have persisted, improved, or worsened over time among US adults. This survey study examined a nationally representative sample of 38 696 adults aged 20 years or older: 6162 SNAP participants, 6692 income-eligible nonparticipants, and 25 842 higher-income individuals from 8 cycles of the National Health and Nutrition Examination Survey (1999-2014). Data analysis was conducted between January 1, 2017, and December 31, 2017. Survey-weighted, energy-adjusted diet by SNAP participation status. Mean diet scores and proportions of US adults meeting poor, intermediate, or ideal diet scores based on the American Heart Association (AHA) 2020 Strategic Impact Goals for diet, including 8 components (fruits and vegetables; whole grains; fish and shellfish; sugar-sweetened beverages; sodium; nuts, seeds, and legumes; processed meats; and saturated fat). The survey included 38 696 respondents (20 062 female [51.9%]; 18 386 non-Hispanic white [69.8%]; mean [SD] age, 46.8 [14.8] years). Participants of SNAP were younger (mean [SD] age, 41.4 [15.6] years) than income-eligible nonparticipants (mean [SD] age, 44.9 [19.6] years) or higher-income individuals (mean [SD] age, 47.8 [13.6] years); more likely to be female (3552 of 6162 [58.6%] vs 3504 of 6692 [54.8%] and 13 006 of 25 842 [50.4%], respectively); and less likely to be non-Hispanic white (2062 of 6162 [48.2%] vs 2594 of 6692 [56.0%] and 13 712 of 25 842 [75.8%], respectively). From surveys conducted in 2003 and 2004 to those conducted in 2013 and 2014, SNAP participants had less improvement in AHA diet scores than both income-eligible nonparticipants and higher-income individuals (change in mean score = 0.57 [95% CI, -2.18 to 0.33] vs 2.56 [95% CI, 0.36-4.76] and 3.84 [95% CI, 2.39-5.29], respectively; P = .04 for interaction). Disparities persisted for most foods and nutrients and worsened for processed meats, added sugars, and nuts and seeds. In 2013 to 2014, a higher proportion of SNAP participants had poor diet scores compared with income-eligible nonparticipants and higher-income individuals (461 of 950 [53.5%] vs 247 of 690 [38.0%] and 773 of 2797 [28.7%]; P < .001 for difference), and a lower proportion had intermediate diet scores (477 of 950 [45.3%] vs 428 of 690 [59.8%] and 1933 of 2797 [68.7%]; P < .001 for difference). The proportion of participants with ideal diet scores was low in all 3 groups (12 of 950 [1.3%] vs 15 of 690 [2.2%] and 91 of 2797 [2.6%]; P = .26 for difference). Dietary disparities persisted or worsened for most dietary components among US adults. Despite improvement in some dietary components, SNAP participants still do not meet the AHA goals for a healthful diet.
Highlights
Unhealthful diet is one of the top contributors to poor health in the United States,[1] and disparities in diet quality by socioeconomic status can contribute to the nation’s health disparities
From surveys conducted in 2003 and 2004 to those conducted in 2013 and 2014, Supplemental Nutrition Assistance Program (SNAP) participants had less improvement in American Heart Association (AHA) diet scores than both income-eligible nonparticipants and higher-income individuals
In 2013 to 2014, a higher proportion of SNAP participants had poor diet scores compared with income-eligible nonparticipants and higher-income individuals (461 of 950 [53.5%] vs 247 of 690 [38.0%] and 773 of 2797 [28.7%]; P < .001 for difference), and a lower proportion had intermediate diet scores
Summary
Unhealthful diet is one of the top contributors to poor health in the United States,[1] and disparities in diet quality by socioeconomic status can contribute to the nation’s health disparities. Low-income individuals have not experienced the same improvements in diet quality as high-income individuals,[2,3] and for consumption of several foods, this disparity may have widened over time.[3]. Among different dietary programs for low-income households, the Supplemental Nutrition Assistance Program (SNAP) is by far the largest and most important safety net program, providing monthly benefits to approximately 1 in 7 US individuals and representing more than half of the annual budget of the US Department of Agriculture (USDA).[4,5] Participants in SNAP experience significantly higher all-cause, cardiovascular, and diabetes mortality compared with other American adults.[6,7,8] Prior studies have shown that disparities exist in diet quality between SNAP participants and higherincome individuals.[9] potential trends in these dietary disparities over time remain unclear
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