Low-income Supplemental Nutrition Assistance Program participation is related to adiposity and metabolic risk factors

The American Journal of Clinical Nutrition, Jan 2012

Leung, Cindy W, Willett, Walter C, Ding, Eric L

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Low-income Supplemental Nutrition Assistance Program participation is related to adiposity and metabolic risk factors

Low-income Supplemental Nutrition Assistance Program participation is related to adiposity and metabolic risk factors1-3 Cindy W Leung Walter C Willett Eric L Ding Background: The Supplemental Nutrition Assistance Program (SNAP) is the largest federal nutrition assistance program. In recent years, SNAP participation rates increased during times of economic hardship. Objective: We examined whether household SNAP participation was associated with adiposity and metabolic risk factors in a representative sample of low-income US adults. Design: A cross-sectional analysis was performed with the use of data from the 2003-2006 National Health and Nutrition Examination Surveys. The study population was restricted to nonelderly adults whose household incomes fell to or ,130% of the federal poverty level. Multinomial logistic and Poisson regression models were fit to examine the associations between SNAP participation and BMI, waist circumference, and metabolic risk factors among 2250 low-income adults. Results: In the previous 12 mo, 32.8% of adults received household SNAP benefits. SNAP participation was positively associated with obesity [prevalence ratio (PR): 1.58; 95% CI: 1.08, 2.31], waist circumference in men (PR for top compared with bottom quartile: 2.04; 95% CI: 1.15, 3.62; P = 0.02), and waist circumference in women (PR: 2.95; 95% CI: 1.51, 5.77; P = 0.003; P-interaction with sex = 0.11), independent of sociodemographic characteristics. SNAP participation was also related to elevated triglycerides (PR: 1.71; 95% CI: 1.33, 2.20), lower HDL cholesterol (PR: 1.23; 95% CI: 1.08, 1.41), elevated fasting glucose ( 110 mg/dL; PR: 1.63; 95% CI: 1.05, 2.52), and metabolic syndrome (PR: 1.49; 95% CI: 1.13, 1.95). Associations with triglycerides and HDL cholesterol persisted after adjustment for BMI. Conclusion: Household SNAP participation was positively associated with BMI, waist circumference, and metabolic risk factors among low-income adults. These associations may be mediated by dietary intake and warrant further investigation. Am J Clin Nutr 2012;95:17-24. - INTRODUCTION The federal SNAP4, formerly the FSP, aims to alleviate food insecurity and improve the dietary intake of participants through benefits to purchase household food items. SNAP eligibility is determined by having a household income at or below 130% of the FPL and ,$2000 in countable assets ( 1 ). In recent years, participation in SNAP has increased dramatically because more households have fallen into poverty ( 2 ). In 2010, $68 billion was spent on SNAP, with 40.3 million persons receiving benefits ( 2 ). Between July 2010 and July 2011, there was a 10.4% increase in SNAP participation among US households ( 3 ). A 2007 USDA report reviewed several previous studies exploring the relation between SNAP participation and obesity ( 4 ). Among children, there appeared to be no association between FSP participation and overweight or obesity; these findings were relatively consistent across data sets and analytic methods. Among adults, longitudinal studies using fixed-effect ( 5, 6 ), discrete factor (7), and bivariate probit models ( 8 ) suggested a positive relation between FSP participation and BMI and obesity in nonelderly adult women, although not in men. However, the magnitude of the associations among women varied widely depending on the data set and the analytic methods used, and many studies used data collected before 2000. Longitudinal studies using dynamic models found no association between FSP participation and BMI ( 9, 10 ). In one of these studies, food insecurity was positively related to BMI among elderly nonparticipants, but was not related to BMI among elderly FSP participants (10). Studies using instrumental variable models have also yielded inconsistent results ( 5, 11 ), likely owing to the difficulty in selecting a valid instrument (12). If a causal relation exists between SNAP participation and BMI, the mechanisms are potentially complicated. The first hypothesized mechanism is that the association may be mediated by dietary behaviors, particularly consumption of inexpensive, energy-dense foods of minimal nutritional value ( 13–15 ). Wilde et al ( 16 ) observed that FSP participants consumed more meats, added sugars, and total fats as a result of program participation. Over time, these foods may contribute to higher total energy 1 From the Departments of Nutrition (CWL, WCW, and ELD) and Epidemiology (CWL and WCW), Harvard School of Public Health, Boston, MA, and the Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (WCW and ELD). 2 Supported by NIH training grant 5 T32 CA009001-35 (to CWL). ELD was supported by a fellowship from the American Diabetes Association. 3 Address correspondence to CW Leung, Department of Nutrition, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA 02115. E-mail: . 4 Abbreviations used: ADA, A (...truncated)


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Leung, Cindy W, Willett, Walter C, Ding, Eric L. Low-income Supplemental Nutrition Assistance Program participation is related to adiposity and metabolic risk factors, The American Journal of Clinical Nutrition, 2012, pp. 17-24, Volume 95, Issue 1, DOI: 10.3945/ajcn.111.012294