There has never been a more important time to be an advocate for nutrition and its role in preventing the many chronic diseases that afflict our country. Once a year, the Academy of Nutrition and Dietetics holds a Public Policy Workshop (PPW) where they invite registered dietitian nutritionists (RDNs) from across the nation to learn about advocacy and participate in Hill visits with their states’ legislators. I had the honor of receiving a scholarship from the Minnesota Academy of Nutrition and Dietetics to attend this year’s PPW in Washington, D.C. This powerful and energizing event starts before you even reach D.C. with a series of 5 webinars that take you on a crash course in effective advocacy and brief you on the issues you will be addressing in your Hill visits. The real fun begins when you arrive in Washington. This year 350 RDNs from all 50 states attended PPW to represent the profession and advocate for the services RDNs provide. The first day includes a workshop that recaps what was discussed in the webinars and gives you an opportunity to meet your fellow state constituents. Together you share stories and formulate how you will present the issues to your legislators the next day. Most meetings are structured in a way that they are conversational but still have the following structure to them:

  1. Clearly state your reason for being there
  2. Provide facts and data that support your cause
  3. Share a personal story
  4. Ask them what you would like them to do
  5. Send a follow-up email within a few days

What surprised me most about this structure was the inclusion of a personal story. But the saying goes, “Data makes you credible, stories make you memorable.” During the Hill visits, I found this absolutely to be true. Personal stories were more relatable and tugged on the heartstrings in a way that reinforced what we were asking the legislators to do.

I had the privilege of meeting with staff members from the offices of Representatives Keith Ellison (D-MN) and Jason Lewis (R-MN), as well as Senators Al Franken (D-MN) and Amy Klobuchar (D-MN). This year’s advocacy work at PPW revolved around two very important topics:

  1. Nutrition education programs in the Farm Bill

What is the issue? 75% of Americans have a diet that is low in fruits and vegetables, which strongly correlates to their risk of developing a chronic disease. A large contributor to poor fruit and vegetable intake is food insecurity and access to affordable nutritious foods. The Supplemental Nutrition Assistance Program (SNAP) is the leading national program in providing nutrition support for families that have food insecurity. In addition to the SNAP program, the Farm Bill authorizes funding toward nutrition education programs, like the SNAP Nutrition Education and Obesity Prevention Grant (SNAP-Ed) and Expanded Food and Nutrition Education Program (EFNEP). These two programs provide funding for local nutrition education initiatives that are designed to meet the needs of the local population.

What did we ask? We asked legislators to fully fund SNAP-Ed and EFNEP in the 2018 Farm Bill.

  1. Value of Nutrition Services in Prevention

What is the issue? Currently, U.S. healthcare costs are $9,990 per person, rendering 3.2 trillion dollars annually. Heart disease, diabetes, and cancer are the leading chronic diseases that contribute to annual healthcare costs. These diseases can be managed or even prevented with evidence-based nutrition interventions provided by trained RDNs. However, insurance companies are not required to provide coverage for nutrition services that have been proven to prevent the onset of these diseases. Currently, Medicare only covers outpatient nutrition services for diabetes, chronic kidney disease, and kidney replacement.

What did we ask? We asked legislators to ensure coverage for nutrition services for all nutrition-related chronic diseases.

On my way back to Minnesota, I reflected on the wonderful connections I made with RDNs from many different states, the stories I heard about the work they do, and the meetings I had with legislator’s staff. After my experience at PPW 2017, I know that advocacy will be a large part of my endeavors when I become a RDN. As Donna Martin, the Academy of Nutrition and Dietetics President-elect, said, “If dietetics is your profession, make policy your passion.” If you even have the slightest interest in advocacy, I urge you to get involved with American Society for Nutrition and other professional organization’s advocacy efforts. You will be happy you did.

 

 

 

The Supplemental Nutrition Assistance Program, known as food stamps until 2008, has its roots in President Franklin D. Roosevelt’s New Deal as a part of the Agriculture Adjustment Act of 1933. This act was an effort to reduce the supply-side surplus of agricultural products, which resulted from the demand for increased exports during World War I. The federal government stepped in to restore the purchasing power of agricultural commodities to the levels seen prior to the war, primarily through the taxation of intermediary processers.

In 1939, the “Food Stamps Plan” was passed and began to resemble the current-day SNAP program. The Food Stamps Plan allowed those with low incomes to purchase food stamps with the benefit of a 50% tax-funded match in additional stamps for restricted use on foods designated to be in a surplus. The special stamps for surplus foods were eliminated in 1961.1

Fast forward to 2016 and SNAP has more than 44 million beneficiaries receiving a monthly payment of $125.50 per individual.2 About two-thirds of SNAP recipients are vulnerable individuals such as children, the elderly, and the disabled.  Of those served, 42% earn incomes below 50% of the poverty line, and 40% earn incomes between 51-100% of the poverty line.3 In general, to qualify for SNAP, the individual can’t make over 130% of the federal poverty line in gross monthly income and no more than 100% of the federal poverty line in net monthly income.4  67% of the SNAP recipients are in the aforementioned category of vulnerable individuals and are not expected to work. Of the remaining 33%, about 14% were employed, and 19% were unemployed.3

In a 2015 report by the United States Census Bureau, SNAP was shown to have kept 4.6 million Americans out of poverty, lowering the overall poverty rate by 1.4%.5 The virtues of injecting SNAP monies into the economy have been touted by many Keynesian economists for the theoretical multiplier benefit of consumption spending on the economy. It has been estimated that every $1 spent in the SNAP program generates $1.79 in economic activity.6 Though this point is debated, framing a safety-net program such as SNAP in terms of its downstream effects on the general economy is removed from the intent of the program, which is to provide aid to individuals in need of sustenance. The SNAP program continues to garner much public support as shown by a recent study, which found that 80% of individuals agreed that SNAP benefits should be raised by 19-43% depending on the scenario.7

The current presidential budget proposal for fiscal year (FY) 2018 entitled A New Foundation For American Greatness suggests cutting the SNAP program by 29% over the next ten years. The proposed budget seems to lament that the typical ebb and flow of this public safety-net program has been replaced in recent years by continual spending increases. SNAP participation usually decreases when the economy is strong and increases when the economy is weak. SNAP reached a historic high during the recession, but even with the improved employment numbers since then, “SNAP participation remains persistently high.” Furthermore, the proposed budget states that the reforms to SNAP will “close eligibility loopholes, target benefits to the neediest households, and encourage work.” Loopholes and safeguards against fraud are important steps to take, especially with the knowledge that the amount of SNAP benefits paid in error totaled $2.2 billion in 2009.8 Prominent forms of SNAP fraud include benefits that are exchanged for cash, embellishment on applications to receive more benefits, and disqualified retailers who continued to accept SNAP.9

The budget proposal also suggests a major structural change to the financing of SNAP. Previously, SNAP was fully funded through the federal government with the states covering the administrative costs, but the new budget proposes a state-federal partnership that will phase in and shift 25% of SNAP costs to the states by 2023.10 The presumable intent of this change in financing is to incentivize states to control costs and put more resources into helping recipients seek employment.

In a Miami Herald op-ed, Mick Mulvaney, director of the U.S. Office of Management and Budget has defended the proposed budget cuts to the SNAP program as a means of making the government more efficient, decreasing the deficit, and allowing individuals to keep more money in their pockets through decreased taxation.11

In the budget proposal, the SNAP program takes the largest cut relative to other public programs. The widespread public support and historical bipartisan support of SNAP makes it hard to foresee the budget passing as proposed without a revision to this particular suggested cut to SNAP. Though the presidential budget is just a recommendation, there are senators on both sides of the aisle who have expressed the sentiment that the budget in its current form is “dead on arrival.”12 House and Senate Appropriations Committees will be considering the FY 2018 spending bills in July after the Independence Day recess so we will soon find out the depth of cuts to the SNAP program.

References

  1. The History of SNAP. SNAP to Health. https://www.snaptohealth.org/snap/the-history-of-snap/. Accessed June 26, 2017.
  2. Supplemental Nutrition Assistance Program (SNAP) Participation and Costs, 1969-2016.; 2017. https://www.fns.usda.gov/pd/supplemental-nutrition-assistance-program-snap. Accessed June 24, 2017.
  3. Chart Book: SNAP Helps Struggling Families Put Food on the Table. Washington, DC; 2017. http://www.cbpp.org/research/food-assistance/chart-book-snap-helps-struggling-families-put-food-on-the-table#part4. Accessed June 25, 2017.
  4. Supplemental Nutrition Assistance Program – Fact Sheet on Resources, Income, and Benefits. https://www.fns.usda.gov/snap/fact-sheet-resources-income-and-benefits. Published 2017. Accessed June 25, 2017.
  5. Renwick T, Fox L. The Supplemental Poverty Measure: 2015. Washington, DC; 2016. https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-258.pdf. Accessed June 24, 2017.
  6. Hanson K. The Food Assistance National Input-Output Multiplier (FANIOM) Model and Stimulus Effects of SNAP.; 2010. https://www.ers.usda.gov/publications/pub-details/?pubid=44749. Accessed June 25, 2017.
  7. Kull S, Ramsay C, Lewis E, Williams A. Americans on SNAP Benefits.; 2017. http://vop.org/wp-content/uploads/2017/04/SNAP_Report.pdf. Accessed June 24, 2017.
  8. Brown K. Supplemental Nutrition Assistance Program: Payment Errors and Trafficking Have Declined, but Challenges Remain.; 2010. http://www.gao.gov/products/GAO-10-956T. Accessed June 24, 2017.
  9. What is SNAP Fraud? https://www.fns.usda.gov/fraud/what-snap-fraud. Published 2017. Accessed June 25, 2017.
  10. A New Foundation For American Greatness – Fiscal Year 2018. Washington, DC; 2017. https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/budget/fy2018/budget.pdf. Accessed June 24, 2017.
  11. Mulvaney M. Mulvaney: The federal budget released today puts taxpayers first. Miami Herald. http://www.miamiherald.com/opinion/op-ed/article152074727.html. Published May 22, 2017. Accessed June 24, 2017.
  12. Gambino L. Republicans voice opposition to Trump’s budget: “Dead on arrival.” The Guardian. https://www.theguardian.com/us-news/2017/may/23/republicans-opposition-trump-budget-medicaid-spending. Published May 23, 2017. Accessed June 25, 2017.

Many dangerous fad diets exist that purport to treat diseases such as cancer by manipulating the pH of blood with different foods. While there is no good evidence that acidic foods alter the body’s pH and promote disease, the hypothesis that “dietary acid load” relates to disease should not be completely dismissed. The kidney serves to regulate blood pH, but if kidney function declines and other tissues catabolize to maintain pH, then it is very plausible that manipulating the diet to reduce the acid load could spare tissues and improve outcomes in chronic kidney disease (CKD). After all, for example, the metabolism of amino acids yields hydrogen ions, whereas fruits and vegetables contain organic salts that generally reduce acid load when metabolized. Recently, a growing number of human studies that manipulate diet acid load using fruits and vegetables and sodium bicarbonate support this hypothesis. Let’s take a look at some of them.

The first randomized controlled trial on bicarbonate supplementation and CKD progression was published in 2009 by de Brito-Ashurst and colleagues. Bicarbonate is produced by the kidneys and serves to neutralize acid. Supplementation of bicarbonate for 1 year in CKD patients slowed the progression of kidney disease as suggested by creatinine clearance and reduced the need for dialysis. The next year, in 2010, a 5-year trial was published by Donald Wesson’s group that found a slowed kidney decline as measured by estimated glomerular filtration rate (eGFR) with bicarbonate supplementation. Several subsequent studies by his group have used bicarbonate or fruits and vegetables to achieve beneficial outcomes. Goraya et al. gave oral bicarbonate or enough fruits and vegetables that were estimated to reduce dietary acid load by 50% to CKD patients for 30 days and also observed a slowed reduction in eGFR in patients at moderate, but not mild, stages of the disease. In patients with more advanced stages of CKD, one year of bicarbonate or fruits and vegetables did not slow the decrease in eGFR, though several urinary markers of kidney injury were reduced. Their most recent trial tested if kidney function might be preserved through a reduction in angiotensin II in moderate stage CKD patients. Three years of bicarbonate or increased fruits and vegetables lessened the decline in eGFR and resulted in a corresponding decrease in the marker angiotensin II. Other studies using bicarbonate from six months to two years have provided strong evidence that reducing acid load consistently slows the decline of eGFR, and improves markers of bone health and muscle function.

Each of the studies described provided fruits and vegetables to patients free of charge to increase adherence. It will be important to test if adherence can be maintained through education alone. Additionally, it may be that “prescribing” fruits and vegetables is effective at improving outcomes and reducing health care costs more so than bicarbonate since they also reduce blood pressure. While “alkaline diets” in general should be viewed skeptically, there is accumulating evidence that fruits and vegetables as dietary alkali do indeed help in kidney disease.