COST-EFFECTIVENESS OF PREFERENTIALLY SUBSIDIZING FRUIT AND VEGETABLE PURCHASES THROUGH THE SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM

Purpose:

A diet high in fruit and vegetable (F&V) is thought to reduce the risk of chronic diseases, including obesity, type II diabetes, and cardiovascular diseases (CVD).  One strategy to incentivize F&V consumption among low-income households is to render them easier to purchase through the Supplemental Nutrition Assistance Program (SNAP). We sought to identify the cost-effectiveness of preferentially subsidizing F&V purchases among the SNAP participants in the U.S. 

Method:

Using data from a randomized trial of F&V subsidies and detailed SNAP participation and dietary consumption data from a nationally-representative sample of Americans completing the National Health and Nutrition Examination Survey (2003-2012), we constructed a stochastic microsimulation model of obesity, type II diabetes, myocardial infarction (MI), and stroke morbidity, mortality, and costs to identify under which circumstances a F&V subsidy would be cost-saving, given observed F&V consumption rates among SNAP users, substitution patterns between food groups, and differences in diseases risks and costs within the SNAP population as compared to the general U.S. population. Sensitivity analyses were conducted to assess whether variations in subsidy levels, duration and enrollment rate of the SNAP could alter the benefits of the program.

Result:

Despite the cycling of participants in and out of the SNAP and the limited responsiveness of populations, subsidizing 30% of F&V purchases through the SNAP would be expected to avert type II diabetes by 1.7% (95% CI: 1.2-2.2), MI by 1.4% (95% CI: 0.9-1.9), stroke by 1.2% (95% CI: 0.8-1.6), and obesity by 0.2% (95% CI: 0.1-0.3). Expanding a F&V subsidy nationwide through the SNAP would be cost-saving from a societal perspective at a total savings of $823 (95% CI: 817-830) with an estimated gain of 0.24 (95% CI: 0.23-0.25) QALYs per capita for the general U.S. population. The costs saved would be conferred largely from long-term reductions in type II diabetes and CVD disease risk, with little impact on obesity. The largest relative benefits were observed among simulated non-Hispanic Blacks, given their high SNAP participation rates, low baseline F&V consumption, and high baseline refined grain consumption.

Conclusion:

A nationwide expansion of F&V subsidy would be expected to significantly reduce chronic disease morbidity, mortality, and costs, but the benefits would be likely to accrue over long time-horizons and unlikely to be observed in short-term community-based trials.