Wednesday, February 3, 2016

dietitians should not try and make snap work

The twitter account for the professional arm of the Academy of Nutrition and Dietetics (AND), @eatrightPRO, recently retweeted the following,

Obviously, Ms. Ehrens heart is in the right place, but there are two problems with her tweet.
First, it promotes the idea that with the right combination of knowledge and skills that it is possible to eat healthy with the allowance afforded by SNAP. This notion is problematic because it concedes that SNAP is sufficient as it is currently structured and therefore could be used to argue against continuing SNAP benefits, or against a future expansion of benefits. Someone who is against the expansion of SNAP could construct an argument along the lines of: (a) Dietitians say that at current benefit levels all it takes is a little knowhow and ingenuity to eat healthy on SNAP, (b) Dietitians are nutrition experts and should therefore be trusted, (c) Thus, SNAP benefits are adequate for ensuring a healthy diet.
Dietitians should want no part of that. AND should want no part of that because as an organization that prides itself on being evidence-based the evidence on poverty is pretty clear: it’s bad.
The second problem with Ms. Ehrens’ tweet is that in reality dietitians possess no special knowledge that for most people dependent on SNAP simply having more money would not fix. For instance, just recently Rogers et al (2015) published work that found pediatric obesity and poverty are highly associated in Massachusetts. Less poor means less overweight/obese. Their findings speak to the fact that dietitians should be arguing for poverty reduction strategies such as a more robust welfare state, or simply making payments to poor patients for attending counseling sessions, rather than repping their own ability to make healthy food choices on the meager budget afforded by SNAP. Obviously, expanding welfare is the preferable option, but paying patients to attend counseling is interesting and could result in a not insignificant cash exchange. Using pediatric obesity as an example, current best practices (see: Barlow, 2007; Lenders, 2016 (in press); Whitlock, 2010) are recommending upwards of 25 contact hours with patients and their family, and may serve to essentially put people deeper into poverty. Wright et al (2014) found that the mean parent-incurred cost per child was $30 for an intervention consisting of approximately 2.2 contact hours (4 25-minute in-person visits, and 2 15-minute telephone calls). For a patient and their family to achieve the 10-25 contact hours that seems to be necessary to make a meaningful change in weight status, the parent-incurred cost would be between $136 and $341 – 1-2 times an average monthly SNAP benefit. And programs that can effectively increase contact hours are in demand. For instance, the CDC is currently funding research to find low-cost interventions that include 25 contact hours and can quickly scale. As similar interventions are established families will be encouraged (or even pressured) to attend an increasing number of visits, but their attendance is costly. And sure, a disease like obesity is associated with significant healthcare costs, but these costs, especially for poor patients, will be borne by the state not the patient. If patients were paid $15 per contact hour we could negate the patient-incurred cost of attendance. If patients were paid even more, say $30 per contact hour that would provide them an additional 10-20% of the average SNAP benefit over a period of six months to a year (the timeframe in which the 10-25 contact hours is recommended). And payments could simply be added to an EBT card, or a new one could be issued. Paying patients will not lift them from poverty (again, expanding welfare is a better option), but it could provide underserved populations some additional income that would allow them to implement changes recommended during visits.

At the risk of rendering a large number of dietitians useless, dietitians should be advocating for an expanded welfare state because poverty is largely the problem, not a lack of nutrition knowledge or food-related skills.

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