By Susan Blumenthal M.D., M.P.A and Sarah Colon
In September, the USDA issued a report with the finding that 14 percent of American households -- 17.4 million families -- were food insecure in 2014. "Food insecurity" means that these households had limited access to adequate food at some point during the year, due to lack of money or other resources. Last week, Hunger Action Month as well as Childhood Obesity Awareness Month came to a close. The convergence of these observances reflects a major public health problem in the United States today -- the widespread co-existence of obesity and hunger in people across the nation. Consider this: While 15.3 million children live in food insecure households, one-third of all American children are obese or overweight.
To address food insecurity in America, three major Federal programs have been established. The Supplemental Nutrition Assistance Program (SNAP) provides monthly benefits to more than 46.5 million low-income Americans that can be used to purchase food at authorized stores. The National School Lunch Program provides federal subsidies to over 100,000 schools and organizations to help provide a nutritious lunch to 30.4 million children every day. Sixty-four percent of those lunches are provided at no cost to the child and another 8 percent are provided at a reduced cost. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides children under age 5, as well as pregnant and postpartum women, with food that meets specific nutritional requirements. WIC serves approximately 8.3 million beneficiaries each month. In 2014, 61 percent of food insecure households received benefits from one of these three Federal food assistance programs.
While these federal programs have greatly improved access to food for low-income families, there is much more that could be done to promote healthier nutritional choices, and combat the co-existence of obesity and food insecurity among low-income populations. SNAP recipients require more education and incentives when it comes to making healthy food choices. Information about nutritional content and lower prices for healthier foods including fruits and vegetables is needed as well. Additionally, innovative strategies to address food deserts, costs, and accessibility of nutritious products are needed to make healthy food choices, the easy choices. Technology and social media can play an important role in providing education about healthier food choices among SNAP and WIC participants.
Currently, SNAP participants use an electronic benefit card (EBT), similar to a debit card, to receive and spend their SNAP benefits. At the beginning of each month, the card is reloaded with a new month's worth of benefits to purchase food. Innovations in EBT technology in the future could be harnessed to help participants make healthier choices and track their food purchases.
Another strategy to promote healthier nutrition in SNAP is to incentivize healthy food purchases. A method for accomplishing this goal is to reduce prices for fresh produce and whole grains for SNAP recipients. The USDA has established pilot programs using vouchers to incentivize the purchase of fruits and vegetables. This initiative should be expanded. Although the 2014 Farm Bill legislation includes initiatives such as the Food Insecurity Nutrition Incentive and the Community Foods Project Program aimed at increasing nutrition for low-income families, there is much more that could be done to encourage healthier food choices.  The USDA's Farmers Market Incentives Provider Study, published in 2014, lists several challenges with the incentive programs for both SNAP recipients and food providers at local farmers' markets. According to the study, while encouraging farmers' markets to accept SNAP benefits has improved food access and healthier nutritional choices among SNAP recipients, the programs are relatively new and more research must be done to evaluate their long term efficacy. Furthermore, many of the organizations supporting these projects have had problems acquiring sufficient funding for their continued support and proper functioning. These challenges highlight the need for a greater focus on the sustainability of incentives programs in farmers' markets and other venues. 
Another strategy to promote healthier food choices is to distribute SNAP benefits several times a month. Additionally, a pilot program could be established that tracks SNAP beneficiaries' purchases and links them to an online rewards system that encourages purchase of healthier products. Once a SNAP recipient has achieved a certain amount of "health points," they might be provided additional benefits or be granted price reductions on healthy food products. A study by the National Center for Biotechnology Information (NCBI) published in 2013, suggests a rewards system can be an effective way to increase healthy food choices. The researchers recommend incentives such as a monthly online raffle for those who have purchased healthy foods, or an increase in monthly benefits for those who have reached a certain healthy food quota. Another recommendation is to generate a list of healthy food options that participants will commit to purchase before coming into the store. The products will then be ready for pick up or delivery at a specified time. This method would decrease impulse buying of unhealthy foods, which are often heavily advertised and placed prominently in stores.
Even if SNAP users become better-educated and incentivized to purchase healthier foods, a serious lack of access to these products in communities across the country presents a major barrier. Many SNAP recipients live in communities with food deserts. The USDA defines a "food desert" as a geographic area without ready access to fresh, healthy, and affordable food. Without supermarkets and grocery stores, these communities are often served only by fast food restaurants and convenience stores, which offer minimal healthy, affordable food options. New initiatives are needed to incentivize supermarkets to build locations in food deserts as well as increase healthy food stocks in corner stores. Other strategies that utilize mobile food delivery such as bulk internet ordering delivered to schools or libraries and mobile food vans could be implemented as well.
Updating SNAP with new tools, innovations and resources requires the input of a broad range of public health, private sector, and governmental stakeholders. SNAP provides an important safety net for low-income families. There are many opportunities to update the program to optimize its potential to promote nutritional health. To achieve this goal, a Federal Task Force should be established with representatives from across government and the private sector to find cost effective solutions to boost healthy nutrition for SNAP participants. Low-income families are disproportionately affected by both food insecurity and overweight/ obesity. Although Hunger Action Month and Childhood Obesity Awareness Month have just passed, it is important to remember that these public health problems affect people in the United States year-round. Innovation in the Federal food assistance programs is needed from all stakeholder groups working together to ensure a healthier future for low-income 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 Tufts and Georgetown University Schools of Medicine. She is also Senior Policy and Medical Advisor at amfAR, The Foundation for AIDS Research. 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. She provided pioneering leadership in applying information technology to health, establishing one of the first health websites in the government (womenshealth.gov) and the "Missiles to Mammogram" Initiative that transferred CIA, DOD and NASA imaging technology to improve the early detection of breast and other cancers. Prior to these positions, Dr. Blumenthal was Chief of the Behavioral Medicine and Basic Prevention Research Branch, Head of the Suicide Research Unit, and Chair of the Health and Behavior Coordinating Committee at the National Institutes of Health. She has chaired many 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 the recipient of the Dr. Rosalind Franklin Centennial Life in Discovery Award.
Sarah Colon is a junior at Dartmouth College majoring in Biological Sciences with a minor in International Studies. She is a Health Policy Intern at New America.
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