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SPECIAL ARTICLE

Behavioral Economics and the Supplemental Nutrition


Assistance Program:
Making the Healthy Choice the Easy Choice
Alice S. Ammerman, DrPH,1,2 Terry Hartman, MPH, MS, CCRC,3 Molly M. DeMarco, PhD1,2

The Supplemental Nutrition Assistance Program (SNAP) serves as an important nutritional safety net
program for many Americans. Given its aim to use traditional economic levers to provide access to
food, the SNAP program includes minimal nutritional requirements and restrictions. As food choices
are influenced by more than just economic constraints, behavioral economics may offer insights and
tools for altering food purchases for SNAP users. This manuscript outlines behavioral economics
strategies that have potential to encourage healthier food choices within the SNAP program.
Am J Prev Med 2017;52(2S2):S145–S150. & 2016 American Journal of Preventive Medicine. Published by
Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

INTRODUCTION conditions simultaneously.8 The problem is now more


commonly one of not “knowing where the next meal is

T
he Supplemental Nutrition Assistance Program
coming from” or lack of access to affordable, healthy
(SNAP) in various iterations has provided critical
food, rather than calorie deficits. Low-income individuals
support to food-insecure individuals for more
are likely able to obtain enough calories but these calories
than 75 years. It has served as an important food safety
may come from cheap foods that are calorie dense and
net program, as evidenced by participation rates increas-
nutritionally poor. Therefore, nutrition and health pro-
ing substantially after the 2008 economic downturn.1
fessionals now increasingly use the term food insecurity,
A recent White House report showed that SNAP has
an economic concept, rather than the biological notion of
played an essential role in lifting families out of poverty
“hunger.”9 Though national survey data show that SNAP
and hunger.2 However, the impact on diet quality has been
participants value nutrition, their time and financial
more modest, and it is evident that SNAP participants, like
constraints complicate the task of making healthy food
most Americans, have substantial room for improvement
choices.10 To address this issue, the U.S. Department of
in the dietary factors most associated with chronic disease
Agriculture (USDA) has developed the Thrifty Food
risk.3,4 The SNAP program is designed around traditional
economic levers, such as income supplementation, but this
alone does not appear adequate to promote healthy From the 1Department of Nutrition, Gillings School of Global Public
Health, University of North Carolina at Chapel Hill, Chapel Hill, North
choices. Behavioral economics offers a collection of Carolina; 2Center for Health Promotion and Disease Prevention (CDC
theories and strategies5,6 that, when implemented, can Prevention Research Center), University of North Carolina at Chapel Hill,
change the environment to “make the healthy choice the Chapel Hill, North Carolina; and 3Sanford School of Public Policy, Duke-
UNC USDA Center for Behavioral Economics and Healthy Food Choice
easy choice” by nudging individuals toward healthier food Research, Duke University, Durham, North Carolina
selection in retail and other food choice situations. Address correspondence to: Alice S. Ammerman, DrPH, Center for
Since the first iteration of SNAP (formerly Food Health Promotion and Disease Prevention; Department of Nutrition,
Gillings School of Global Public Health and School of Medicine, University
Stamps) was implemented in 1939, nutrition-related of North Carolina at Chapel Hill, Chapel Hill NC 27599. E-mail:
health challenges have changed markedly. The program alice_ammerman@unc.edu.
was initially designed to address protein/calorie insuffi- This article is part of a supplement issue titled The Supplemental
ciency and also had a role in reducing agricultural Nutrition Assistance Program's Role in Addressing Nutrition-Related
Health Issues.
surpluses.7 The U.S. now faces a food insecurity–obesity 0749-3797/$36.00
paradox, where many individuals suffer from both http://dx.doi.org/10.1016/j.amepre.2016.08.017

& 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. Am J Prev Med 2017;52(2S2):S145–S150 S145
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
S146 Ammerman et al / Am J Prev Med 2017;52(2S2):S145–S150
Plan, which promotes affordable recommendations to economic levers such as price, income supports, and
follow the Dietary Guidelines for Americans predicated on information are creating opportunities to foster healthier
the fact that people are primarily cooking at home.11,12 food intake among SNAP recipients.
Though potentially lacking adequate refrigeration, meal In a review for the Economic Research Service of
preparation facilities, or transportation, some SNAP and USDA, Just and colleagues20 addressed the question
other low-income families may have to rely heavily on “Could behavioral economics help improve diet quality
non-perishable processed calorie-dense foods to help for nutrition assistance program participants?” In recog-
stretch SNAP benefits to the end of the month.10,13 nizing that food choices are determined by factors beyond
The SNAP program provides the potential for many traditional economic forces, Just suggests that behavioral
families to purchase healthier food. Other USDA nutrition economics can “illuminate a broad array of strategies to
assistance programs such as the Special Supplemental influence consumers’ food choices.” In doing so, beha-
Nutrition Program for Women, Infants, and Children vioral economics expands the list of possible strategies for
(WIC) are restricted to “healthier” foods consistent with improving the diet quality and health of participants in
the Dietary Guidelines for Americans. However, SNAP has USDA nutrition assistance programs such as SNAP.
very few restrictions on the type of foods that can be
purchased, giving the consumer more flexibility and free- BEHAVIORAL ECONOMICS AND HEALTH
dom of choice. With flexibility comes the potential to make
either healthy or less healthy choices. The SNAP-Ed PSYCHOLOGY TRIGGERS
(education) program, also funded by the USDA, represents Behavioral economics triggers that can lead to either
the most far-reaching nutrition education program avail- healthy or unhealthy food choices can help to identify
able for low-income consumers. SNAP-Ed is funded at a potential areas for nudging SNAP recipients toward
level of more than $400 million annually and seeks to reach healthier choices. Many of these approaches overlap or
95 million Americans with incomes below 185% of the work best in coordination.
Federal Poverty Level.14 It is designed to help low-income
individuals, including those on SNAP, make healthful food Choice Architecture
and physical activity choices. The SNAP-Ed Toolkit15 Choice architecture refers to an approach to influencing
includes a list of SNAP-Ed interventions that have been consumer decision making through the design of environ-
reviewed and deemed evidence based for broader dissemi- ments in which choices are made. Consumers often describe
nation. In 2010, the SNAP-Ed program added obesity “willpower” as the missing factor that prevents them from
prevention, along with nutrition education, to its mandate making and maintaining healthy dietary change. This
and embraced changes to the policies, systems, and construct relates to the ability to resist temptation and make
environments that facilitate better food choices by low- the behavioral decisions and actions required to stick to a
income consumers. Behavioral economic theory is being plan for improved nutrition. However, the current food
incorporated into interventions in traditional (supermar- environment creates temptations and messages encouraging
kets and convenience stores) and non-traditional (farmers’ less healthy food choices; willpower is easily overwhelmed.
markets and food co-ops) retail environments to nudge Choice architecture can be used to create environments
consumers toward healthier food choices.16–18 These inter- where healthy choices are more obvious and easier to make,
ventions can be used to nudge SNAP recipients and other requiring much less in the way of self-control or willpower.
low-income consumers through the SNAP-Ed program. An example of how choice architecture can be used with the
Behavioral economics has been popularized by books SNAP population is through product placement within the
such as Nudge5 and Switch.19 The subtitle to Nudge is retail setting. Healthier food items can be placed on end
“Improving Decisions About Health, Wealth, and Happi- caps, at eye level, or near the checkout aisles. Another
ness,” whereas for Switch it is “How to Change Things approach to choice architecture involves default options—
When Change Is Hard.” Together, these phrases capture pre-set courses of action that transpire without any decision
the challenges faced by SNAP recipients, who have limited making required of the consumer. One default option may
resources and time, making healthy food choices that be to couple the new provision of the recent farm bill that
much harder. Behavioral “nudges” are a key component of allows the purchase and delivery of foods to homebound
behavioral economics. As defined by the authors of Nudge, elderly or disabled SNAP participants with limiting the
Thaler and Sunstein,5 “A nudge is any aspect of the choice selections of food available for purchase to healthier items.21
architecture that alters behavior in a predictable way
without forbidding any options or significantly changing Cues
their economic incentives.” Behavioral nudges and food Cues are important environmental triggers that can
psychology in combination with more-traditional either tempt one into making bad decisions or remind

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Ammerman et al / Am J Prev Med 2017;52(2S2):S145–S150 S147
23
the consumer that they are trying to make healthy produce. Other strategies include bundling of healthier
changes. Cues and environmental triggers are used food options such as salad ingredients or vegetable stir
extensively in the Smarter Lunchroom intervention fry. Bundling is often used by retailers to increase sales or
developed and tested at the USDA-funded Cornell move perishable products. This could mean a win–win
Center for Behavioral Economics in Child Nutrition.22 between SNAP customers and grocers because bundling
Those implementing Smarter Lunchrooms place fresh of produce in set dollar amounts can facilitate purchase
fruit in an appealing, well-lit bowl. They might also place by SNAP customers needing to stay within their SNAP
chocolate milk behind the healthier dairy options so it is allotment. Budgeting is easier when the cost of a set
less visible and harder to reach. Potential cues for SNAP amount of produce is known versus finding out when
participants may include placing healthy, economical weighed at the time of checkout.
food items in prominent locations, including checkout,
improving lighting at displays of healthier options, or Salience
creating visually appealing displays within grocery retail Salience pertains to the availability of necessary informa-
outlets frequented by SNAP shoppers to promote their tion at the point of decision. For example, WIC partici-
sale. Although there is evidence that these cues work in pants often find it difficult to identify WIC-approved
the short run, it is less clear whether they continue to foods when not clearly labeled. “Shelf talkers” and
nudge behavior change after the novelty has worn off. grouping healthier options on aisle end caps use beha-
vioral economics strategies to put healthier options in
Present Bias/Hyperbolic Discounting front of customers and make their purchase easier. End
Present bias/hyperbolic discounting refers to the ten- caps change frequently to market different products as
dency for people to choose a smaller/sooner reward over they depend on the salience of change to get the
a larger/later reward, and thus greater emphasis on the consumer’s attention. Most studies of end caps and
present and on pleasurable inputs, at the expense of healthier food choices are based on short-term trials.
considering future implications such as adverse health More research is needed to determine the willingness of
outcomes associated with poor dietary choices. Although retailers to maintain healthier end caps and whether
not unique relative to other shoppers, this is an under- nudges toward healthy choices have a persistent impact
standable problem facing a low-income SNAP shopper over time. The aforementioned bundling example may be
with a young child or two riding in his shopping cart. another way to use salience to nudge SNAP customers
Pleasing an irritable child can easily trump choosing the toward healthy choices because the necessary informa-
healthiest options. To combat the desire to choose a tion (exact produce price) is provided.
smaller/sooner reward and save SNAP funds for other
purchases, grocery outlets could provide healthy snacks Pre-commitment
to children as they are shopping with their parents. In Pre-commitment involves making choices or partial
fact, recently some supermarket retailers have begun decisions prior to entering a more tempting environ-
offering a complementary piece of fresh fruit to children ment, at a time when one can be more thoughtful about
while shopping with an adult. Not only does this send a the challenges of “present bias.” A simple example is
message that the retailer cares about customer well-being using a shopping list and sticking to it. Pre-commitment
(by offering a healthy option as opposed to the frequently also offers a number of interesting opportunities within
offered free cookies), it may be an effective business the SNAP program. As mentioned above, the most recent
strategy to increase customer purchases of that fruit farm bill permits food ordering and delivery programs to
if the child decides he or she likes it, thus serving as a become authorized SNAP retailers if they meet SNAP
behavioral cue as well. requirements and serve elderly and disabled SNAP
recipients who are unable to come to a retail location
Cognitive Overload to shop for food.21 Placing an order from home while not
Cognitive overload can impair decision making owing to tempted by the many options in a grocery store and
the complexity or volume of information, such as reading perhaps using SNAP-Ed tools that nudge toward heal-
and interpreting food labels or determining the unit cost thier choices may lead to better diet quality. In another
of a product. This can be a significant problem in a development, SNAP recipients are now able to use their
typical grocery store that stocks up to 42,000 different benefits to pay for “shares” in a Community Supported
items. Creative approaches have shown promise in retail Agriculture program. Members generally buy a “share”
establishments, using simple cues such as arrows on the in a local farm at the beginning of the season and then
floor pointing toward the produce section or grocery receive a box of seasonal fresh produce each week.
basket signs encouraging greater selection of fresh Non-profit and for-profit farmers’ markets and direct

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S148 Ammerman et al / Am J Prev Med 2017;52(2S2):S145–S150
marketing farmers that operate a Community Supported purchase of perishable products, such as fruits and
Agriculture model can accept payment up to 14 days in vegetables, throughout the month. This is a change that
advance of delivering the food to the SNAP customer or could be made at the state level and has already been
making the food available for pickup. This is a form of implemented in Michigan.27 However, even with spread-
pre-commitment, as those SNAP funds are “committed” ing of benefits over time, without a healthier food
to fresh farm produce and thus not available to purchase environment, nutrition education, or behavioral nudges,
less healthy items from traditional retailers. the result could still be poor food choices. As described
above, the SNAP-Ed program has identified evidence-
Loss/Risk Aversion based interventions in a toolkit for SNAP-Ed providers
Loss/risk aversion refers to people’s tendency to strongly that could address this concern (toolkit),15 through
prefer avoiding immediate losses over acquiring longer- educating consumers on stretching the food dollar or
term gains. A recent study suggests that low-income using SNAP to purchase and preserve seasonal bulk (and
primary caregivers choose to minimize the cost of thus less expensive) produce from farmers markets or
uneaten and thus wasted foods by choosing to purchase farm stands through canning or freezing. More research is
more calorie-dense, processed foods they know their needed to understand whether more-frequent food SNAP
children will eat. Higher-income caregivers, who have the benefit issuance would result in better food choices.
resources to withstand the cost of uneaten food, are more
likely to repeatedly introduce healthier food items that Subsidizing Healthy Foods
their children might reject at first but learn to like over Studies have shown that subsidizing the purchase of
time.24 It is easy to see how the loss/risk aversion among healthy foods can raise the consumption of these items.
lower-resource caregivers like SNAP recipients could The 2008 Farm Bill authorized $20 million for pilot
impact their children’s taste acquisition and longer- projects to determine if incentives provided to SNAP
term eating habits.24 This suggests the need for new food recipients at the point of sale increase the purchase of
introduction and taste testing in schools and other fruits, vegetables, or other healthful foods. This effort was
settings where the cost associated with early refusals is referred to as the Healthy Incentives Pilot (HIP). Under
not absorbed by the consumer. Strategies to make it easy HIP, SNAP participants received an incentive of 30 cents
to let parents know when children try and like a healthy for every SNAP dollar spent on targeted fruits and
food while at school or in child care could also increase vegetables credited back to their SNAP Electronic Benefit
the SNAP caregiver’s willingness to try serving the food Transfer card. The incentive could then be spent on any
at home. The aforementioned idea of a healthy snack SNAP-eligible foods and beverages. Study results show
provided to a child while shopping with the parent is that HIP participants consumed 26% more targeted fruits
another way to address risk aversion among SNAP and vegetables than non-HIP participants—about 0.25
recipients as their child gets to try a new food item with cup more per day—and purchased a greater variety
no monetary risk to the parent. of fruits and vegetables.28 The Agriculture Act of 2014
(P.L. 113-79) authorized USDA to provide grant funds to
BEHAVIORAL ECONOMICS AND SNAP eligible organizations to design and implement point of
purchase incentive projects to increase fruit and vege-
POLICY table purchases among SNAP participants. USDA is
There are a number of ways in which SNAP Policy at the funding a number of projects through this Food Inse-
national or state level can build on or facilitate behavioral curity Nutrition Incentive Grant Program29 and is
economics approaches to further enhance healthy food conducting an independent evaluation. This cost offset
choices.25 assistance is a more direct economic lever to purchasing
more fruits and vegetables.
More-Frequent SNAP Benefit Issuances
Some SNAP advocates have proposed the idea to break the Retailers’ Food Stocking Requirements
food stamp cycle of receiving all benefits at the beginning As required by the 2014 Farm Bill, USDA has proposed a
of the month and running out by the end of the month by rule designed to provide SNAP participants increased
spreading out benefits issuance over the month and access to healthy foods by requiring stores that accept
avoiding lean times at the end of the month. Because SNAP to stock a wider array of food choices. The
SNAP participants are more likely to use the majority of stocking provisions in the proposed rule would require
their benefits when they first receive them instead of SNAP-authorized retail establishments to offer seven
budgeting to last throughout the month,26 twice-monthly varieties of qualifying foods in four staple food groups
versus monthly payments could be useful to facilitate the for sale on a continuous basis, along with perishable

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Ammerman et al / Am J Prev Med 2017;52(2S2):S145–S150 S149
foods in at least three of the four staple food groups. The industry has used the strategy of pre-commitment to
staple foods groups are dairy products; breads and support consumer desire for self-control or willpower.
cereals; meats, poultry, and fish; and fruits and vegeta- Almost half of Americans worry about their weight “all” or
bles. A focus of the proposed rule is to increase healthier “some of the time.” Fear of overconsumption of highly
food access in areas where consumers might depend on palatable foods has resulted in a substantial market for
smaller grocery, convenience, and gas-mart retailers for 100-calorie packs of snack foods. By purchasing these
an increasing volume of their food purchases in the limited portion size packages, consumers are pre-
absence of more-traditional and larger food retailers. committing that they will eat only what is in the package
Research regarding current stocking practices of non- they purchased, as opposed to trying to limit their intake
traditional retailers suggests that implementing these from a standard package of cookies. Although it is always
rules may be challenging for smaller retailers. Assisting possible to eat a second or third 100-calorie packet, the
retailers to implement the new SNAP stocking require- packs are perceived as an aid to weight control efforts for
ments, including nudges to encourage purchases of the which consumers are willing to pay more. Interestingly,
newly stocked items, represents a behavioral economics consumers revolted when the same strategy was proposed
approach to adapting to new SNAP regulations.30 Nud- in New York City regarding SSB portion size, with
ging consumers toward purchases of fresh or frozen consumers seeing it as an affront to free choice. Of course
fruits and vegetables when they are not accustomed to in this case, food companies were not benefiting from the
buying these foods in a small convenience store has the sale of a smaller portion size. The Leung article31 in this
potential to help retailers with stocking requirement issue presents an interesting opportunity in that it adds to
implementation. the evidence that a majority of SNAP consumers approve
of restricting SSB access on the program, particularly when
Pre-order and Home Delivery paired with a healthy food incentive (SNAPþ). Taking a
As described above under pre-commitment strategies, page from the food industry 100-calorie snack package
new SNAP rules will allow consumers to order foods for playbook, perhaps such a strategy could be “sold” to SNAP
delivery or to prepay with SNAP in certain situations. participants as a way to assist them with healthier choices
More work is needed to study the impact of these rule for their family using behavioral economic strategies,
changes, but there is significant potential to overcome incentivizing healthier choices, and removing the need
access barriers as well as create behavioral nudges toward for SSB self-control, thus making the healthy choice easier.
healthier choices. In addition, such flexibility can help
reduce the stigma associated with program participation.
DISCUSSION AND CONCLUSIONS
Food Restrictions The SNAP program serves as an important federal food
Limiting foods allowed on the SNAP program could be safety net for many in the U.S. Given its aim to use
described as a default option approach in behavioral traditional economic levers to improve access to food, the
economics. As described above, the WIC program uses SNAP program includes minimal food restrictions. Food
this approach by providing food benefits but prescribing choice, however, is influenced by more than just eco-
the specific foods that can be purchased. There is nomics. Consumers make complicated decisions about
currently much debate about the strategy of restricting how to spend their food dollars every day. The behavioral
the type of foods that can be purchased on SNAP. Most economics strategies discussed here may offer useful tools
often mentioned is removing sugar-sweetened beverages to encourage healthier food choices within the SNAP
(SSBs) from eligible SNAP foods, given mounting program. This manuscript outlines behavioral economics
evidence that SSBs are strongly associated with obesity strategies that have the potential to encourage healthier
and diabetes. Those opposing this idea have held that it is food choices by SNAP participants. However, more
a paternalistic approach and that the primary benefit of research is needed in this promising area to determine
SNAP is as an income supplement. Proponents, on the the impact and inform future policy directions.
other hand, believe that the SSBs contribute only
negatively to a healthy diet and that SNAP participants
are often targeted by beverage advertising. Several articles ACKNOWLEDGMENTS
in this journal supplement address the pros and cons of
Publication of this article was supported by the Physicians
restricting SSBs on SNAP benefits. Committee for Responsible Medicine. The findings and conclu-
Behavioral economics strategies and psychology could sions in this article are those of the authors and do not
be useful in helping “win over” consumers to a policy that necessarily represent the official position of the Physicians
would remove SSBs from SNAP benefits. The food Committee for Responsible Medicine.

February 2017
S150 Ammerman et al / Am J Prev Med 2017;52(2S2):S145–S150
Funding for this study is provided by the Duke-UNC USDA 13. Ploeg MV, Mancino L, Todd JE, Clay DM, Scharadin B. Where do
Center for Behavioral Economics and Healthy Food Choice Americans usually shop for food and how do they travel to get there?
Research, which is funded by grant 59-5000-4-0062 from the Initial findings from the National Household Food Acquisition and
U.S. Department of Agriculture. The authors express their Purchase Survey. Economic Information Bulletin. 2015;138.
sincerest gratitude to Dr. Joanne Guthrie, Dr. Anita Singh, and 14. U.S. Department of Agrigulture. Supplemental Nutrition Assistance
Barbara Murphy from the U.S. Department of Agriculture for Program Education (SNAP-Ed). www.fns.usda.gov/snap/supplemen
tal-nutrition-assistance-program-education-snap-ed. Published 2016.
their thoughtful review and comments in the development of
Accessed July 1, 2016.
this manuscript. 15. U.S. Department of Agriculture, Food and Nutrition Service. SNAP-Ed
The views expressed in our research are those of the strategies & interventions: an obesity prevention toolkit for states.
investigators and cannot be attributed to the U.S. Department https://snaped.fns.usda.gov/snap/SNAPEdStrategiesAndIntervention
of Agriculture, its Economic Research Service, or its Food and sToolkitForStates.pdf. Published 2016. Accessed April 24, 2016.
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this paper. doi.org/10.1016/j.physbeh.2014.03.029.
17. Payne CR, Niculescu M, Just DR, Kelly MP. Shopper marketing
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