The SNAP program, for the most part, operates independently of the health system. Applicants aren’t required to meet with a health professional, and most internists and other adult medical specialists don’t routinely make direct referrals to the program.
But what if SNAP were more like WIC, and referrals to the program became second nature for clinics serving chronically ill, low-income people? I don’t want to add to the lengthy laundry list of problems for which primary care physicians are expected to screen. But some aspects of the WIC program, such as its close collaboration with health departments, hospitals and clinics, as well as its heavy focus on education, might provide a model for how the SNAP program could work with health professionals.
“We should get smarter about how to address these things at a clinic or health system level,” Berkowitz said.
One idea might be for clinic check-in staff to screen patients for food insecurity when they arrive for their appointment, perhaps by having them answer some questions on a tablet or mobile phone that would automatically trigger a referral to SNAP. It doesn’t have to be complicated—one study found that a single question—“In the past month, was there any day when you or anyone in your family went hungry because you did not have enough money for food?”—was effective at determining food insecurity among parents at a clinic serving low-income children.
Another idea might be to provide some healthy foods to patients directly at the doctors’ office. A Spanish study published in The New England Journal of Medicine last year randomized more than 7,000 patients who were at high risk of heart disease to a “Mediterranean diet,” which included free supplies of extra-virgin olive oil or a mix of walnuts, almonds, and hazelnuts, or to counseling on a low fat diet that recommended fruits, vegetables, fish, low-fat dairy and bread, potatoes, pasta or rice.
At the end of five years, the people in the Mediterranean diet groups were significantly less likely to have had a stroke than those in the low fat diet “control” group. (There was no significant difference in heart attacks or in the overall death rate, however.)
Some doctors have adopted the strategy of providing healthy food “prescriptions” to low-income children and their families. In 2010, pediatrician Shikha Anand collaborated with Wholesome Wave, a nonprofit, to establish the Fruit and Vegetable Prescription Program, which enables teams of doctors, nurses and nutrition educators to prescribe vouchers that can be redeemed for free produce at local farmers’ markets. Early data suggests the program is effective in increasing fruit and vegetable consumption and in reducing body mass index, a measure of weight, among overweight and obese children.
"There's a growing body of evidence that this program affects food security," Dr. Anand said. "It's not just the effect of getting the prescription, it's the effect of engaging in that conversation about the connection between food and health with that primary care team that you know and trust."