One very frustrating thing about living in 21st century America is that is seems perfectly acceptable for reporters and politicians to say or print just about anything, and immediately have it unquestioningly accepted by the vast majority of the voting public. Critical thinking, honesty and the quality of reporting seem to hit new lows each and every week. Perhaps this would not be so irritating if the fate of everyone’s standard of living, healthcare and personal happiness did not hang in the balance, but as often as not those are exactly the stakes involved.
One example that caught our attention recently was a Ron Nixon piece in The New York Times entitled “House Plan on Food Stamps Would Cut 5 Million From Program” – an article that begins with an attention-getting opening line that immediately alludes to the sort of cruelty usually associated with Josef Stalin or the Great Leap Forward of Mao Zedong:
WASHINGTON — Nearly half a million people who receive food stamps but still do not get enough to eat would lose their eligibility for the program under proposed cuts that are expected to be taken up again by Congress. An additional 160,000 to 305,000 recipients who do get enough to eat would also lose their eligibility and the ability to adequately feed themselves.
In total, about 5.1 million people would be eliminated from the program, according to a new report.
Starvation in America. Given our status as one of the most obese nations on the planet, this indeed a cruel irony. But while the average reader might be excused for conjuring up mental images of emaciated children and lean Dust Bowl Okies, we soon learn that reducing the number of food stamp recipients from 47 million to 42 million will be a healthcare disaster for entirely different reasons. Namely, reducing the amount of food consumed by poor Americans is going to increase the incidence of diabetes, obesity, hypertension and heart disease.
“What?” you’re probably asking, “Having Americans consume fewer calories is going to lead to more diabetes and obesity? I thought that our current plague of diabetes and obesity was caused by eating too much rather than eating too little.” Well there’s your problem. You’re thinking too much rather than relying on journalists and experts.
The Health Impact Project, a Washington research group, released a study on Tuesday about the impact of the proposed cuts to the food stamp program. The project is a collaboration between the Robert Wood Johnson Foundation and the Pew Charitable Trusts.
The report said the cuts to the program, also known as the Supplemental Nutrition Assistance Program, or SNAP, would not only affect the ability of low-income households to feed themselves but would also increase poverty.
The combination of poverty and a lack of food would lead to increases in illnesses like heart disease, diabetes and high blood pressure among adults, the study found. In children, the cuts would lead to higher rates of asthma and depression. Diabetes alone could increase federal and state health care costs by nearly $15 billion over the next 10 years, the report found.
“The SNAP program has implications for health, and we wanted to make sure that health is part of the debate,” said Dr. Aaron Wernham, the director of the project. “There is a large body of public health research which shows how food insecurity affects health.”
Since common sense and experts can’t both be right and the total cost of the SNAP program is set to exceed $80 billion in 2013, the journalist in us feels compelled to look a little further into this particular story in an attempt to ferret out the truth. On what basis does this apparently influential report suppose that a lack of food stamps (and presumably therefore food), actually cause diabetes, obesity, heart disease and so on – such that simply trimming the program will increase their incidence?
It seems that the study underlying the assertion that giving poor people fewer calories causes diabetes and obesity can be found here. Three academic researchers, one from the University of California, Davis, one from Northwestern University and the third from Columbia University looked at the relationship between the time food stamps were implemented in specific counties throughout the U.S. and the subsequent incidence of diabetes, obesity, high blood pressure, obesity, heart attacks and “metabolic syndrome” (the combination of obesity, high blood pressure and diabetes) in two population samples selected in 1968. The first was a representative sample of approximately 3,000 households and their descendants. The second was a sample of 1,900 low-income and minority “high risk” households. The question the investigators wanted to answer was: “Was there a relationship between the introduction of food stamps into a household’s county of residence, and the subsequent incidence of these illnesses in the households in question? If so, is the change specifically linked to having food stamps available during pregnancy and early childhood?”
That these investigators were looking for such a relationship was hardly random. They cite previous studies showing that serious problems encountered in utero and in early childhood can affect long term income, health status, wages and educational achievement. Examples include famine, and exposures to diseases and radiation. One theory that has evolved as a result of these observations is that perhaps an infant’s body is “programmed” for long-term survival based upon the conditions that it sees in utero and in the first few years thereafter.
During development, the fetus (and post-natally the child) may take cues from the current environment to predict the type of environment it is expected to face in the long run and in some cases adapts its formation to better thrive in the expected environment. A problem arises, however, when the predicted later environment and the actual later environment are substantially different. For example, if nutrients are scarce during the pre- (or early post-natal) period, the developing body therefore predicts that the future will also be nutritionally deprived. The body may then invoke (difficult-to-reverse) biological mechanisms to adapt to the predicted future environment. For example, the metabolic system may adapt in a manner that will allow the individual to survive in an environment with chronic food shortages. This pattern is termed the “thrifty phenotype” and is sometimes referred to as the Barker hypothesis. The “problem” arises if in fact there is not a long-run food shortage, and nutrition is plentiful. In that case, the early-life metabolic adaptations are a bad match to the actual environment and will increase the likelihood that the individual develops a “metabolic disorder,” which is the clustered association between high blood pressure (hypertension), type II diabetes, obesity and cardiovascular disease.
Since food stamps were rolled out on a county by county basis throughout the U.S. between 1962 and 1975, the investigators wanted to see if there was empirical evidence that new and ongoing access to food stamps at different stages of infant development would influence the development of obesity and related diseases in later life. To accomplish this they did a regression analysis, which is a statistical method that attempts to describe the degree with which measured outcomes can be ascribed to a particular variable. In this case, the variable in question is whether individuals had access to food stamps between conception and the age of five (“FS share IU-5”).
Well? What did they find?
The main results we’re interested in for the “High Impact” (i.e., poor) population are shown in Table 2 shown below. (*** indicates that a result is significant to p=0.01, * indicates p=0.10. The outcome coefficient in the first row (e.g., -0.294***) means that this fraction of the variation in the outcome can be explained by the presence or absence of food stamps in early childhood.)
As you can see, there was a highly significant correlation between the early availability of food stamps in poor and minority population and the later onset of metabolic syndrome. Altogether, the presence or absence of access to food stamps explained about one-third of the elevated risk of metabolic syndrome in this population. There was also a slightly, but statistically questionable reduction in obesity generated by early access to food stamps. However there was no significant correlation between early food stamp access and diabetes, high blood pressure, heart disease or heart attack as independent outcomes (i.e., not associated with metabolic syndrome). So there may be something to the “early life programming” theory with respect to metabolic syndrome and maybe even with relation to obesity, but not with respect to the long-term risk of diabetes, high blood pressure or heart disease.
How many people in the “High Impact” sample actually developed metabolic syndrome? Apparently about 1%. That’s just one-fifth of the people who developed diabetes, and less than one-thirtieth of those who became obese. So overall, we don’t seem to be talking about a major impact on the population most at risk.
But there are other problems with taking these results and blithely asserting that a 10% reduction in food stamp beneficiaries will increase healthcare costs due to this particular biological mechanism. For one thing, in order for the programmed developmental changes associated with metabolic syndrome to occur, pregnant women, infants and small children have to be exposed to nutritional deficits over a very specific period of biological development – early childhood. Depriving teenagers, adults and the elderly of food stamps can be expected to have little or no impact.
Interestingly enough there just happens to be a federal food program for that, and it’s not SNAP. It’s called the Women, Infants and Children Program, or “WIC”. WIC is a USDA food program was rolled out in 1972 and made permanent in 1974 – right at the end of the nationwide rollout of food stamps. WIC is available in all 50 States, 34 Indian Tribal Organizations, American Samoa, District of Columbia, Guam, Commonwealth of the Northern Mariana Islands, Puerto Rico, and the Virgin Islands. Ninety WIC State agencies administer the program through approximately 1,836 local agencies and 9,000 clinic sites. And who does WIC happen to serve? Low-income pregnant and breastfeeding women, as well as children through the age of five. That just happens to be the same group – and the only group – for whom food stamps have been shown to be of benefit for preventing metabolic syndrome and obesity.
Lest we worry that WIC is some pint-sized program that doesn’t have much demographic reach:
During Fiscal Year (FY) 2011, the number of women, infants, and children receiving WIC benefits each month averaged almost 9 million participants per month. In 1974, the first year WIC was permanently authorized, 88,000 people participated. By 1980, participation was at 1.9 million; by 1990, 4.5 million; by 2000, 7.2 million; and by 2010, 9.2 million. Children have always been the largest category of WIC participants. Of the 8.9 million people who received WIC benefits each month in FY 2011, approximately 4.7 million were children, 2.1 million were infants, and 2.1 million were women.
It seems fair to say that, after the development of the food stamp program, the federal government doubled down by launching a new additional program specifically targeted toward those who would be most at risk for developing metabolic syndrome. This raises the question of whether the extra food assistance contributed by SNAP is medically necessary if your goal really is to prevent obesity, diabetes, high blood pressure and heart disease? Is more food assistance always better?
This is an increasingly important question in light of some convincing recent research that suggests that food stamps themselves are contributing to obesity.
This work comes from Jay Zagorsky at Ohio State University and the Patricia Smith at University of Michigan, Dearborn. Published in 2009, Zagorsky and Smith’s work took a comprehensive look at the differences between populations that were identically matched for income, county of residence, education and a host of other factors, but differed with respect to whether they participated in the food stamp program:
In this study, Zagorsky and Smith compared nearly 4,000 survey participants who used food stamps with almost 6,000 survey participants who did not. They looked at BMI and food stamp use among the participants from 1989 to 2002…
Obesity has been linked to poverty, so the researchers took into account income and a variety of other factors – including race and education — that may have also affected the weight of survey participants, outside of the use of food stamps.
In addition, the study compared people who lived in the same counties, to take into account that there may be local factors that affect obesity rates.
Even after the various controls, the link between food stamp use and higher weight remained clear, especially for women.
While female food stamp users in general had an average BMI that was 1.24 points higher than those not in the program, white women’s BMI was 1.96 points higher, while black women’s BMI was 1.1 points higher.
Male food stamp users, both white and black, did not have significantly higher BMIs than those not in the program.
Additional evidence of food stamps’ role in weight gain came when the researchers looked at how people’s BMI changed before, during and after they were on food stamps.
Results showed BMI increased over all three periods, but increased the most when participants were on food stamps.
The average food stamp users saw their BMI go up 0.4 points per year when they were in the program, compared to 0.07 points per year before and 0.2 points per year after they no longer received the benefits.
In addition, the study found the longer participants received food stamps, the higher their BMI.
“Every way we looked at the data, it was clear that the use of food stamps was associated with weight gain,” Zagorsky said.
One very interesting result from this study is that the use of income, education and location-matched controls suggests that food stamps themselves are an actual cause of the problem. One argument that frequently arises is that poor people have to buy high-fat, high-calorie food because those are the foods that are cheap, and/or they don’t know which foods are healthy. But if that’s the case, why is it that equally poor and uneducated people (but who are clearly not starving, judging by their own average BMI) are actually thinner? The obvious answer is that SNAP benefits are themselves an unhealthy source of extra calories.
Other economics research certainly seems to support this interpretation. We would point our readers to an interesting 2010 paper by Charles L. Baum II at Middle Tennessee State University:
The Food Stamp Program potentially increases obesity by increasing food consumption, resulting in excessive caloric intake. Food stamps potentially increase food consumption by making the monetary cost of food zero for eligible individuals up to their food stamp allotment (though since Food Stamp Program participation rates are well below 100 %, non-monetary costs such as stigma
and the opportunity cost of applying and re-certifying for the benefits likely remain significant). A survey of the literature suggests a dollar of food stamps increases food consumption between $0.17and $0.47, which is more than an equivalent amount of cash would (Fraker1990). It is not surprising that this would be true for constrained households, but this also appears to be true for the other 85 to 95 % of food stamp households that are unconstrained (Fraker1990).
Although recipients could potentially use food stamps to buy healthier foods, recent evidence by Wilde, McNamara, and Ranney (1999) suggests food stamp recipients consume significantly more sugar and fat than eligible non-recipients. Additional evidence by Whitmore (2002) indicates that food stamp recipients in San Diego and Alabama in the 1990s consumed more soft drinks than peers who instead received cash benefits. If so, then it is possible that recipients not only consume more food, they consume more of the foods likely to lead to weight gain.
Baum’s own research goes on to conclude that food stamps do contribute to obesity, but their total impact is small relative to the overall U.S. obesity epidemic. This shouldn’t be surprising since most Americans are overweight, but “only” 47 million currently participate in SNAP. What should be surprising, however, is that well-funded and prestigious organizations like the Robert Wood Johnson Foundation and the Pew Charitable Trust apparently missed all of this research in their recent report. It seems that there are a good reasons that witnesses asked to testify in court are exhorted to “tell the truth, the whole truth, and nothing but the truth.” If only we had the same standard when it comes to media and healthcare reporting.
Based upon everything we’ve seen so far, at least three key observations can be made about health, disease and food stamps.
First, we should all be very skeptical about health claims made on behalf of specific political actions. Consider some recent examples. The huge federal subsidies and penalties legislated for the use or non-use of electronic medical records were justified on the basis of financial and medical benefit claims which were inflated at best, and even fraudulent. The Affordable Care Act was supposed to save money and make healthcare more efficient – something that seems laughable in retrospect. Now cutting food stamp programs will cause obesity, diabetes and (directly or indirectly) death. The common denominator in all of these claims is the use of healthcare and medicine to justify what are essentially political (and often lobbyist) agendas.
Second, with respect to the specific issue of food stamps raised by the Nixon New York Times article, it seems safe to say that the WIC program has removed much or all of the potential risk of metabolic syndrome and obesity occurring as a direct result of pregnancy and childhood-related caloric deficiency in the U.S.
Finally, from a medical and health perspective the SNAP program is broken. Part of the problem is that SNAP benefits can be used for a host of high-calorie, high-fat foods that directly contribute to obesity and health complications in the poor. SNAP benefits now pay directly or indirectly for fast food, cookies, birthday cakes, soft drinks, “energy drinks”, Twinkies, Ho-Hos, Ding Dongs, candy bars, Cheez-Its and a host of other junk foods that would prove excellent fodder for fattening hogs. In fact, food stamps are used to purchase about $2 billion worth of sugary drinks each year, even as the rest of state, federal and local governments are spending billions to discourage their use. Lowering the cost of these foods to essentially zero is a disservice to anyone, let alone those who might struggle to keep their weight down under the best of circumstances. Is the food stamp program trying to help these people, or kill them with kindness?
It appears that substantial portions of the Road to Hellth are paved with food stamps.