title: Effects of Subsidies and Prohibitions on Nutrition in a Food Benefit Program: A Randomized Clinical Trial.
abstract: Strategies to improve the nutritional status of those participating in the Supplemental Nutrition Assistance Program (SNAP) are of interest to policymakers.
  
  
  
  To evaluate whether the proposed policy of incentivizing the purchase of fruits and vegetables and prohibiting the purchase of less nutritious foods in a food benefit program improves the nutritional quality of participants' diets.
  
  
  
  Lower income participants (n = 279) not currently enrolled in SNAP were randomized to 1 of 4 experimental financial food benefit conditions: (1) incentive (30% financial incentive for fruits and vegetables purchased using food benefits); (2) restriction (not allowed to buy sugar sweetened beverages, sweet baked goods, or candies with food benefits); (3) incentive plus restriction (30% financial incentive on fruits and vegetables and restriction of purchase of sugar sweetened beverages, sweet baked goods, or candy with food benefits); or (4) control (no incentive or restrictions on foods purchased with food benefits). Participants in all conditions were given a study-specific debit card where funds were added every 4 weeks for a 12-week period. Outcome measures were collected at baseline and in the final 4 weeks of the experimental period.
  
  
  
  Primary outcomes (from 24-hour dietary recalls) included intake of energy, discretionary calories, and overall diet quality.
  
  
  
  A number of favorable changes were observed in the incentive plus restriction condition that were significantly different from changes in the control condition. These included (1) reduced intake of energy (-96 kcal/d, standard error [SE], 59.9); (2) reduced intake of discretionary calories (-64 kcal/d, SE 26.3); (3) reduced intake of sugar sweetened beverages, sweet baked goods, and candies (-0.6 servings/d, SE 0.2); (4) increased intake of solid fruit (0.2 servings/d, SE 0.1); and (5) improved Healthy Eating Index score (4.1 points, SE 1.4). Fewer improvements were observed in the incentive only and restriction only arms.
  
  
  
  A food benefit program that pairs incentives for purchasing more fruits and vegetables with restrictions on the purchase of less nutritious foods may reduce energy intake and improve the nutritional quality of the diet of participants compared with a program that does not include incentives or restrictions.
  
  
  
  clinicaltrials.gov Identifier: NCT02643576.
authors.affiliation: Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis.
authors.forename: Lisa
authors.initials: L
authors.lastname: Harnack
authors.affiliation: Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis.
authors.forename: J Michael
authors.initials: JM
authors.lastname: Oakes
authors.affiliation: Department of Population Health, School of Medicine and Wagner School of Public Service, New York University, New York.
authors.forename: Brian
authors.initials: B
authors.lastname: Elbel
authors.affiliation: Agricultural and Resource Economics, University of California-Davis, Davis.
authors.forename: Timothy
authors.initials: T
authors.lastname: Beatty
authors.affiliation: Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis.
authors.forename: Sarah
authors.initials: S
authors.lastname: Rydell
authors.affiliation: Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis.
authors.forename: Simone
authors.initials: S
authors.lastname: French
mesh_terms: D000328:Adult; D001628:Beverages; D015992:Body Mass Index; D000072001:Diet, Healthy; D004041:Dietary Fats; D002149:Energy Intake; D005247:Feeding Behavior; D005260:Female; D005500:Follow-Up Studies; D063105:Food Assistance; D005638:Fruit; D006801:Humans; D008297:Male; D008875:Middle Aged; D009752:Nutritional Status; D009753:Nutritive Value; D009765:Obesity / Q000517:prevention & control; D010349:Patient Compliance; D011203:Poverty; D012307:Risk Factors; D016037:Single-Blind Method; D014481:United States; D014675:Vegetables
chemical_list: D004041:Dietary Fats