RESEARCH AND PRACTICE

The Supplemental Nutrition Assistance Program, Food

Insecurity, Dietary Quality, and Obesity Among US Adults
Binh T. Nguyen, PhD, Kerem Shuval, PhD, Farryl Bertmann, PhD, and Amy L. Yaroch, PhD

Food insecurity, broadly defined as having

Objectives. We examined whether Supplemental Nutrition Assistance Pro-
limited access to adequate food,1 is associated
gram (SNAP) participation changes associations between food insecurity,
with increased stress levels and reduced overall
dietary quality, and weight among US adults.
well-being.2 In addition, food insecurity has Methods. We analyzed adult dietary intake data (n = 8333) from the 2003 to
been shown to diminish dietary quality and 2010 National Health and Nutrition Examination Survey. Bivariate and multivari-
affect nutritional intake and has been associ- able methods assessed associations of SNAP participation and 4 levels of food
ated with chronic morbidity (e.g., type 2 di- security with diet and weight. Measures of dietary quality were the Healthy
abetes, hypertension) and weight gain.1,3---5 In Eating Index 2010, total caloric intake, empty calories, and solid fat; weight
2012, approximately 14.5% of US households measures were body mass index (BMI), overweight, and obesity.
(17.6 million households) experienced food Results. SNAP participants with marginal food security had lower BMI (1.83
insecurity, of whom 5.7% (7.0 million house- kg/m2; P < .01) and lower probability of obesity (9 percentage points; P < .05).
SNAP participants with marginal (3.46 points; P < .01), low (1.98 points; P < .05),
holds) experienced very low food security
and very low (3.84 points; P < .01) food security had better diets, as illustrated by
(i.e., reduction in food intake).6 The Supple-
the Healthy Eating Index. Associations between SNAP participation and im-
mental Nutrition Assistance Program (SNAP),
proved diet and weight were stronger among Whites than Blacks and Hispanics.
formerly known as food stamps, is the largest Conclusions. Our research highlights the role of SNAP in helping in-
government assistance program in the United dividuals who are at risk for food insecurity to obtain a healthier diet and
States and seeks to alleviate food insecurity better weight status. (Am J Public Health. 2015;105:1453–1459. doi:10.2105/
in US households.7 SNAP has the potential to AJPH.2015.302580)
mitigate the adverse effects of food insecurity
on health outcomes not only through attenu-
ating food insecurity but also by enhancing the and weight status warrant further investigation from an in-home questionnaire, as well as
dietary quality of its participants.8,9 to inform SNAP programming, policy, and obtaining dietary data and medical and phys-
Although cross-sectional studies have found outreach to ultimately improve the health and iological measurements and performing labo-
no significant differences in food insecurity well-being of SNAP participants. We explored ratory tests and a physical examination in
levels between SNAP participants and nonpar- these relationships in data from the National mobile examination centers.18
ticipants,10,11 in a longitudinal study, Nord Health and Nutrition Examination Survey We focused on participants with family income
observed a 28% reduction in the odds for very less than 200% of the federal poverty level in
(NHANES) over multiple years. We aimed to
low food security among households that 2003 to 2010 to reduce residual confounding in
determine mitigating effects SNAP participa-
remained on SNAP throughout the year rela-
tion might have on the association of food the sample, especially between the high-income
tive to those who left before the last 30 days
insecurity with dietary quality and obesity food security group and other groups. We did not
of the year.12 In addition, studies by Leung and
among a nationally representative sample of limit our sample to SNAP-eligible participants
Villamor13 and Webb et al.14 found that in-
US adults. with incomes lower than 130% of the federal
dependent of food insecurity, SNAP participa-
poverty level because we aimed at capturing both
tion is associated with the increased likelihood
of obesity, and other studies have observed
METHODS the marginal food security and food insecurity
lower dietary quality specifically among SNAP population, many of whom are not eligible for
The NHANES is a multistage, cross-sectional, SNAP.6,19 Thus our sample consisted of 8333
participants.15,16 Kreider et al. used partial
nationally representative survey conducted by nonpregnant adults aged 20 years and older who
identification bounding methods to take into
account the endogenous selection and misre- the National Center for Health Statistics to had completed day 1 dietary interviews.
porting of SNAP enrollment and found that explore the health and nutritional status of US
SNAP reduced the prevalence of food insecu- children and adults.18 Our participants came Measures
rity, poor general health, and obesity among from 4 waves: 2003 to 2004, 2005 to 2006, We determined participation in the SNAP
children.17 2007 to 2008, and 2009 to 2010. The program by an affirmative response to the
Thus, the interrelationships among SNAP NHANES collects information on demographic question, “In the last 12 months, did [you, or
participation, food insecurity, dietary quality, and socioeconomic characteristics and health any member of your household] receive food

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 RESEARCH AND PRACTICE

stamp benefits?”18 We derived 4 levels of food an ordinary least squares model with the in- of respondents’ households, marginal in
security from responses to the NHANES Food teraction coefficient of SNAP and food security. 13.2%, low in 17.2%, and very low in 10.5%.
Security Survey Module questionnaires, details Our formula was The bivariate relationship of food security
of which are available online.20 Households status to dietary quality and weight status is
with high food security reported no food access ð1ÞY ij ¼ aij þ bSNAP j þ cFoodInsec j presented in Table 2. Participants with any
problems or limitations; households with mar- þ aSNAP j · FoodInsec j þ dij X ij þ eij level of food insecurity had a significantly
ginal food security may have had anxiety over lower HEI-2010 score than those with full food
Where Y ij , the dependent variables, denoted
food sufficiency or shortage of food in the security (43.7 vs 46.6), higher intake of added
outcomes of individual i in household j; aij was
house; households with low food security sugar (22.0 vs 18.7 teaspoons), and higher
the intercept; b was a parameter estimate for
generally reported reduced quality, variety, or intake of empty calories (787.9 vs 731.5
the baseline difference between SNAP partici-
desirability of diet without changes in diet or kilocalories; P < .05 for all). Furthermore, in-
pants and SNAP nonparticipants; and c was an
food intake; and households with very low food dividuals living in households without food
estimate for the difference between 4 levels of
security generally reported multiple indications security had significantly higher BMIs and
food security. The main parameter of interest,
of disrupted eating patterns and reduced food were likelier to be obese than those with food
a, was an estimate of the cross-level interac-
intake. We considered households in the high security (38.4% vs 33.7%; P < .01). How-
tions of a household’s SNAP status and food
and marginal categories to be food secure. ever, we observed no significant differences
security.
Our key outcome variables were (1) diet (the in solid fat consumption or the probability
Other control covariates (Xij ) were age; gender;
Healthy Eating Index 2010 [HEI-2010]21 and of being underweight.
race/ethnicity (non-Hispanic White, non-Hispanic
intake of added sugar, solid fat, empty calories, The association of SNAP participation and
Black, Hispanic, other); education (< high school,
and total calories) and (2) weight (body mass food security status with dietary quality and
high school, some college, ‡ college); marital
index [BMI], defined as weight in kilograms weight status among low-income respondents
status (married, never married, divorced or
divided by the square of height in meters; is presented in Table 3. SNAP participants had
separated, widowed); poverty-to-income ratio;
overweight; and obesity). From the first-day a poorer nutrient profile (lower HEI-2010
dietary recall data (24 hours), we computed Women, Infants, and Children program par- score, higher consumption of added sugar, solid
HEI-2010 as well as other dietary indicators, ticipation in the past year; health insurance fat, and empty calories) than nonparticipants.
such as empty calorie, solid fat, and added- status (insured or not); employment status HEI-2010 scores were lowest among partici-
sugar intake, with National Cancer Institute (employed or not); whether the survey was pants who reported living in households with
methodology.22 We used HEI-2010, a tool that completed on a weekday or weekend24; and very low food security (2.59 points lower than
aims to determine compliance with the 2010 interview wave (2003---2004, 2005---2006, in the reference group, participants with high
Dietary Guidelines for Americans, to assess 2007---2008, 2009---2010). food security), followed by those with marginal
overall dietary quality.21 We calculated BMI We conducted all statistical analyses with (–2.27 points), and low (–1.63 points) food
with the standard formula and objectively STATA version 1325 and accounted for the security.
measured height and weight. We used World NHANES complex, multistage probability sam- Table 3 also shows the interaction between
Health Organization criteria to categorize par- pling design of households and individuals to SNAP participation and food security (i.e., whether
ticipants’ BMI as underweight (<18.5 kg/m2), enable nationally representative estimates.26 SNAP participation may change the associations
normal weight (18.5---< 25 kg/m2), overweight Because individuals in the mobile examination between food insecurity, dietary quality, and
(‡ 25---< 30 kg/m2), or obese (‡ 30 kg/m2).23 centers sample provided the dietary recall data, weight status among US adults). Participation in
we used the centers’ sample weights (provided SNAP was associated with higher HEI-2010
Statistical Analysis by NHANES) in all analyses. We computed scores (better nutrient profile) among individ-
We used the first-day 24-hour dietary recall HEI-2010 scores with SAS software version uals in households with marginal (+3.46
data to document participants’ sociodemo- 9.3.27 points), low (+1.98 points), and very low
graphic characteristics by participation status in (+3.84 points) food security than among re-
the SNAP program. We also examined the RESULTS spondents with corresponding food insecurity
differences in HEI-2010 score and intake of who did not receive SNAP benefits. For
added sugar, solid fat, empty calories, and total The characteristics of the study population participants with low food security, partici-
calories among those with full food security are shown in Table 1. The study sample pating in SNAP was only associated with
versus all others (i.e., participants with mar- consisted of 8333 adults. Participants had lower added-sugar (–3.88 teaspoons) and
ginal, low, and very low food security). In a mean age of 45.5 years; 55.4% were empty calorie (–67.56 kcal) intake. Although
addition, we examined the differences in per- women, 55.9% were non-Hispanic Whites, SNAP participants and respondents experi-
centage of underweight, overweight, and obe- 16.4% were non-Hispanic Blacks, 21.9% encing food insecurity each independently
sity and in BMI between these 2 groups. were Hispanics, 51.1% were married, 64.5% had a higher BMI and higher probability of
To examine the combined effect of SNAP had health insurance, and 49.2% were being obese, the combined association of
participation and food security, we estimated employed. Food security was high in 59.1% SNAP participation and food insecurity

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 RESEARCH AND PRACTICE

previous research with our finding that SNAP

TABLE 1—Summary Statistics of Low- TABLE 1—Continued participation among those who do not have
Income Adults: National Health and full food security might protect against a less
Wave
Nutrition Examination Survey, 2003– healthful diet and obesity. Specifically, we
1 (2003–2004) 24.1
2010 found that the interaction between SNAP par-
2 (2005–2006) 23.0
Full Sample 3 (2007–2008) 26.2 ticipation and marginal, low, or very low food
Variable (n = 8333) 4 (2009–2010) 26.7 security was associated with higher dietary
quality and lower BMI. The interaction be-
Women, % 55.4 Note. FPL = federal poverty level; SNAP = Supplemen- tween SNAP participation and food insecurity
Age, y, mean 45.5 tal Nutrition Assistance Program; WIC = Women,
Infants, and Children program. Results take survey was significantly associated with a lower likeli-
SNAP participation, % 27.3
weights into account. Respondents were aged 20 hood of obesity only among the marginal food
Household food security,a % years or older and had family income under 200% of security group. This result aligns with Hanson
Full 59.1 the FPL.
a
Respondents from households with children younger et al., who studied the interaction between food
Marginal 13.2
than 18 years were asked 18 questions from the US insecurity, marital status, and body weight and
Low 17.2 Food Security Survey Module; respondents from found that food insecurity was related to
Very low 10.5 households without children were asked 10 questions.
The food insecurity variable, with 4 response levels, a greater likelihood of obesity among married
Race/ethnicity, %
was derived from affirmative responses. Household full women with marginal food security.28
Non-Hispanic White 55.9 food security = zero affirmative responses; marginal Because the recession of 2007 to 2009 was
Non-Hispanic Black 16.4 food security = 1–2 affirmative responses; low food
security = 3–5 affirmative responses for households associated with a record high rate of job loss,
Hispanic 21.9
without children 3–7 affirmative responses for low rate of reemployment, and substantial
Other 5.9 households with children; very low food security = earnings losses,29 the population of persons
Marital status, % 6–10 affirmative responses for households without
children and 8–18 affirmative responses for house- temporarily experiencing marginal food secu-
Married 51.1
holds with children. rity is expected to grow.30 SNAP could play
Widowed 9.6
a prominent role in ensuring that this popula-
Divorced/separated 17.1
tion has the necessary resources to obtain
Never married 22.2
participation had limited effect on dietary a nutritionally adequate diet during difficult
Education, %
quality and weight status among food-insecure times.31 On the other hand, it is important to
< high school 35.7
non-Hispanic Black adults. By contrast, SNAP understand the reasons some participants are
High school 28.3
participation among food-insecure non-Hispanic still unable to consume healthy food, whether it
Some college 26.6
Whites was associated with a higher HEI-2010 is because of inadequate SNAP benefit, insuf-
‡ college 9.4
score for respondents with marginal (+5.29 ficient time to shop for and prepare nutritious
Health insurance, % 64.5
points), low (+3.92 points), and very low meals, or lack of nutrition knowledge and
Currently employed, % 49.2
(+4.83 points) food security as well as with budgeting skills.
Received WIC benefits in 21.1
lower overall BMI among participants with Our results also showed that adults with-
past year, %
marginal (–2.59 kg/m2) and very low (–2.03 out full food security had a higher intake of
Poverty-to-income ratio, FPL, %
kg/m2) food security. Among Hispanic adults, total calories, added sugar, and empty calo-
0–50 12.3
SNAP participation was related to lower ries than those with full food security. Re-
51–100 27.1
added-sugar consumption (–3.15 teaspoons) search shows that food insecurity, often
101–130 20.4
lower BMI (–1.54 kg/m2), and lower likeli- a cyclic phenomenon, is associated with
131–200 40.2
hood of obesity (–12 percentage points) preferences for energy-dense foods, because
Household size, mean 3.3
among the marginal food security group. adults who anticipate future food scarcity
Survey on weekend, % 39.0
often overconsume when food is available.32
Continued DISCUSSION Moreover, food-insecure persons, who are
often low income, may be hesitant to pur-
We analyzed nationally representative data chase nutrient-rich foods such as fruits and
appeared to decrease BMI across all 3 to determine whether SNAP participation vegetables, which cost more per calorie than
food-insecure groups and reduce the likelihood modified the associations between food inse- energy-dense foods with minimal nutritional
of obesity among participants with marginal curity and individuals’ dietary quality and values.33---35 Those who experience food in-
food security (9 percentage points). weight. Consistent with the literature, we found security may also not have the means to
Table 4 presents the associations of SNAP that food insecurity and SNAP participation, travel to buy food frequently and may opt to
participation and food security with dietary independently, were associated with lower di- purchase nonperishable or canned products
quality and weight status, stratified by race/ etary quality and a higher prevalence of obesity or energy-dense foods that are less healthy,
ethnicity. These results indicated that SNAP among adults.15,16 In addition, we augmented yet less costly.36

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 RESEARCH AND PRACTICE

TABLE 2—Food Security, Dietary Quality, and Weight Status Among US Low-Income Adults: National Health and Nutrition Examination Survey,
2003–2010

Full Sample (n = 8333), No. or % Full Food Security (n = 4645), No. or % Food Insecurity (n = 3688), No. or % Pa

Dietary quality
Healthy Eating Index 2010, total score 45.4 46.6 43.7 < .001
Added sugar, teaspoons 20.1 18.7 22.0 < .001
Solid fat, g 399.5 398.1 401.5 .768
Empty calories, kcal 754.6 731.5 787.9 < .001
Total calories, kcal 2128.8 2103.0 2166.2 .084
Weight (BMI)
Continuous 28.8 28.5 29.2 < .001
Underweight (£ 18.5 kg/m2) 2.3 2.3 2.4 .607
Overweight (£ 25–< 30 kg/m2) 31.6 32.6 30.2 .178
Obese (‡ 30 kg/m2) 35.6 33.7 38.4 < .001

Note. BMI = body mass index. Results take survey weights into account. Not full food security group includes people living in households with marginal food security, low food security and very low
food security.
a
Difference between full food security and any category of food insecurity derived from Student t test.

Our subgroup analysis revealed that SNAP weight status only in households with marginal groups, low-income Blacks and Hispanics often
might affect racial/ethnic groups differentially: food security. live in segregated neighborhoods, especially in
interactions between SNAP participation and One possible explanation of SNAP’s differen- inner cities.38 Studies have found that residents
food insecurity benefited dietary quality and tial modification of the association of food in- of mixed-race or solely Black neighborhoods
weight status among Whites (all food insecurity security to dietary intake and weight status is (regardless of income) are less likely than those
groups) to a much greater extent than among neighborhood disparities in access to healthy in predominantly White communities to have
Blacks. Among Hispanics, SNAP participation food.37 Although low-income Whites tend to access to healthy food choices,39 even if they
was associated with improved diet quality and live in neighborhoods with other socioeconomic have SNAP benefits.37 Many studies have

TABLE 3—Multivariable Regression Analysis on Associations of Supplemental Nutrition Assistance Program Participation and Food Insecurity
With Dietary Quality and Weight Status Among US Low-Income Adults: National Health and Nutrition Examination Survey, 2003–2010

Dietary Quality Weight Status

Healthy Eating Index Added Sugar Solid Fat Empty Calories BMI (continuous; Overweight Obese (n = 8174),
(n = 8333), b (SE) (n = 8333), b (SE) (n = 8333), b (SE) (n = 8333), b (SE) n = 8174), b (SE) (n = 8174), b (SE) b (SE)

SNAP –3.18** (0.53) 2.53** (0.74) 18.65 (11.70) 53.34** (19.70) 2.10** (0.28) –0.03 (0.02) 0.12** (0.02)
Household food security
Marginal –2.27** (0.55) 0.48 (0.77) –14.31 (12.10) –15.79 (20.36) 0.63* (0.29) –0.01 (0.02) 0.04* (0.02)
Low –1.63** (0.53) 2.35** (0.73) –3.19 (11.52) 17.44 (19.39) 0.47 (0.28) –0.03 (0.02) 0.04* (0.02)
Very low –2.59** (0.67) 4.94** (0.94) 13.31 (14.77) 102.48** (24.87) 1.02** (0.35) –0.02 (0.02) 0.05* (0.02)
SNAP · marginal food security 3.46** (0.99) –1.42 (1.37) 15.84 (21.64) 0.54 (36.43) –1.83** (0.52) 0.00 (0.03) –0.09* (0.03)
SNAP · low food security 1.98* (0.88) –3.88** (1.22) –21.50 (19.36) –67.56* (32.58) –0.98* (0.46) 0.00 (0.03) –0.05 (0.03)
SNAP · very low food security 3.84** (1.04) –2.99* (1.44) –11.59 (22.76) –65.24 (38.32) –1.17* (0.55) 0.02 (0.04) –0.06 (0.04)

Note. BMI = body mass index; FPL = federal poverty level; SNAP = Supplemental Nutrition Assistance Program; WIC = Women, Infants, and Children program. Respondents were aged 20 years or
older and had family income under 200% of the FPL. Values are coefficients derived from ordinary least squares regressions. Dependent variables were healthy eating index (maximum score = 100),
added sugar (teaspoons), solid fat (grams), empty calories (kilocalories), BMI (continuous value), overweight (dummy variable), and obesity (dummy variable). These dependent variables were
regressed on variables indicating SNAP participation, households’ food security categories (dummy variables), and SNAP participation interacted with food security categories. Control variables were
age, race/ethnicity, income (via poverty income ratio groups), marital status, education, insurance status, WIC participation, and employment status. Results take survey weights into account.
*P < .05; **P < .01.

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 RESEARCH AND PRACTICE

TABLE 4—Multivariable Regression Analysis on Racial/Ethnic Differences in Associations of Supplemental Nutrition Assistance Program
Participation and Food Insecurity With Dietary Quality and Weight Status Among US Low-Income Adults: National Health and Nutrition
Examination Survey, 2003–2010

Dietary Quality Weight Status

Healthy Eating Added Sugar, Solid Fat, Empty Calories, Overweight, Obese,
Index, b (SE) b (SE) b (SE) b (SE) BMI, b (SE) b (SE) b (SE)

Non-Hispanic Blacks (n = 1768)

SNAP · marginal food security –0.29 (1.79) –2.85 (2.50) –22.08 (41.81) –33.41 (69.78) –0.69 (1.15) 0.03 (0.06) –0.06 (0.07)
SNAP · low food security 0.00 (1.67) –2.13 (2.33) 22.61 (38.85) –16.69 (64.84) –0.55 (1.07) 0.05 (0.06) –0.08 (0.06)
SNAP · very low food security 3.04 (1.90) –2.45 (2.65) –1.48 (44.34) –9.86 (74.01) –0.39 (1.22) 0.07 (0.07) –0.06 (0.07)
Non-Hispanic Whites (n = 3398)
SNAP · marginal food security 5.29** (1.71) 1.55 (2.55) 29.15 (37.54) 74.62 (64.89) –2.59** (0.88) –0.06 (0.06) –0.08 (0.06)
SNAP · low food security 3.92* (1.53) –7.93** (2.29) –34.38 (33.69) –143.90* (58.23) –1.07 (0.79) –0.07 (0.05) –0.00 (0.05)
SNAP · very low food security 4.83** (1.76) –5.01 (2.63) –37.63 (38.73) –127.06 (66.94) –2.03* (0.91) 0.04 (0.06) –0.09 (0.06)
Hispanics (n = 2806)
SNAP · marginal food security 2.55 (1.60) –3.15 (1.73) 48.45 (33.16) –34.12 (50.81) –1.54* (0.72) 0.14* (0.06) –0.12* (0.06)
SNAP · low food security 1.53 (1.42) –1.26 (1.53) –36.13 (29.48) –38.27 (45.17) –0.64 (0.64) 0.06 (0.05) –0.05 (0.05)
SNAP · very low food security 1.43 (1.78) –1.31 (1.93) 3.25 (37.01) –52.44 (56.71) –0.24 (0.80) –0.01 (0.07) –0.01 (0.06)

Note. FPL = federal poverty level; SNAP = Supplemental Nutrition Assistance Program; WIC = Women, Infants, and Children program. Respondents were aged 20 years or older and had family income
under 200% of the FPL. Values are coefficients derived from ordinary least squares regressions. Dependent variables were healthy eating index (maximum score = 100), added sugar (teaspoons),
solid fat (grams), empty calories (kilocalories), BMI (continuous value), overweight (dummy variable), and obesity (dummy variable). These dependent variables were regressed on variables
indicating SNAP participation, households’ food security categories (dummy variables), and SNAP participation interacted with food security categories. Control variables were age, race/ethnicity,
income (via poverty income ratio groups), marital status, education, insurance status, WIC participation, and employment status. Results take survey weights into account.
*P < .05; **P < .01.

assessed food deserts (low-income areas with in meeting the challenge of consuming a health- represent longer-term dietary intake pat-
limited access to fresh, healthy, and affordable ful diet on a limited budget.46,47 In addition, terns.49---51 In addition, we could not establish
food)40,41 and policies, such as the Healthy SNAP-Ed interventions have begun addressing a causal relationship because of the cross-
Food Financing Initiative, that have been de- environmental factors affecting dietary intake, sectional nature of the data. Furthermore, we
veloped to address these inequities.42 Fur- such as providing access to more healthful foods could not control for self-selection into SNAP,
thermore, dietary intake disparities may turn (e.g., fruits and vegetables) in local corner or which could have been affected by such un-
into discrepancies in the incidence and man- convenience stores, which are more prevalent in observed factors as personal preferences and
agement of obesity, hypertension, diabetes, and low-income neighborhoods.48 underlying health conditions. Therefore, our
other diet-sensitive chronic diseases.4,32 Thus, Our findings are consistent with the litera- identification strategy, similar to many studies
further research is needed to better understand ture suggesting that racial/ethnic groups may in the literature,11 did not permit us to identify
why and how government nutrition assistance differ in taking advantage of government as- the causal effects of SNAP participation on
programs such as SNAP can affect varying sistance programs, so interventions encourag- health behaviors and outcomes.
food-insecure populations differently and to ing increasing utilization of SNAP and SNAP-Ed Our results were derived from self-reported
assess the possible solutions. and incorporating promotion of more healthful food security and SNAP participation status,
The Department of Agriculture has continued food consumption should be tailored to ethnic which may reflect an individual’s own percep-
to make improvements to the SNAP-Education minority subgroups. These programs will help tion rather than the actual situation, and the
(SNAP-Ed) program, specifically to enhance the not only food-insecure populations, but also reported numbers were subject to possible
quality of SNAP participants’ diets.16,43,44 The the marginally food secure, to achieve a more measurement error (e.g., misreporting or mis-
main aim of SNAP-Ed is to improve the likeli- healthful diet and consequently improve classification bias).52 For example, weight sta-
hood that SNAP participants will make healthier health outcomes and well-being. tus may influence reported food insecurity:
food choices within a limited budget.43 Research obese individuals may be more likely to report
shows that nutrition education programs can Limitations food insecurity because of their habits and
lead to healthier food choices among low- As a self-reported dietary recall data set, perceptions about food consumption.28,53
income households participating in SNAP,45 NHANES may be prone to overestimation of However, although our measure of food in-
and thus SNAP-Ed could aid SNAP participants portion size and dietary intake and may not security relied on self-report,6,17 it adhered to

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 RESEARCH AND PRACTICE

the Department of Agriculture classification, 3. Coleman-Jensen A, Nord M, Andrews M, Carlson S. 20. US Dept of Agriculture. Food security in the U.S.—
Household food security in the United States in 2010. survey tools. 2014. Available at: http://www.ers.usda.
which is regarded as the gold standard.3,6
2011. Available at: http://ssrn.com/abstract=2116606 gov/topics/food-nutrition-assistance/food-security-in-
Future research should aim to enhance un- or http://dx.doi.org. Accessed July 3, 2014. the-us/survey-tools.aspx#.U7qhOPldUSV. Accessed July
derstanding of the interrelationship of SNAP 4. Seligman HK, Laraia BA, Kushel MB. Food in-
7, 2014.
and food insecurity with health outcomes and security is associated with chronic disease among low- 21. National Cancer Institute. Applied research: cancer
income NHANES participants. J Nutr. 2010;140(2): control and population sciences. Healthy Eating Index.
account for both selection bias and measure-
304---310. 2012. Available at: http://appliedresearch.cancer.gov/
ment error, as in a few works on related tools/hei. Accessed February 4, 2014.
5. Laraia BA. Food insecurity and chronic disease. Adv
topics.17,54 Nutr. 2013;4(2):203---212. 22. Guenther PM, Casavale KO, Kirkpatrick SI, et al.
Update of the Healthy Eating Index: HEI-2010. J Acad
6. Coleman-Jensen A, Nord M, Singh A. Household Food
Nutr Diet. 2013;113(4):569---580.
Conclusions Security in the United States in 2012. Washington, DC: US
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