Dietary Supplements: Purchase with Food Stamps

Order Code RL31452 Report for Congress Received through the CRS Web Dietary Supplements: Purchase with Food Stamps June 11, 2002 Donna V. Porter Specialist in Life Sciences Domestic Social Policy Division Congressional Research Service ˜ The Library of Congress Dietary Supplements: Purchase with Food Stamps Summary Since 1994, nine bills have been introduced to allow dietary supplements to be purchased with food stamp benefits. In the 107th Congress, a provision in the Senate version of the farm bill would have added vitamin and mineral supplements to the items that can be purchased with food stamps. The provision also would have required a 2-year study to determine the impact of this change on the program’s administration and participants. The provision was not adopted in the conference on the farm bill with the House. The use of dietary supplements is often promoted as a solution to a number of nutrition problems, including general dietary patterns and nutrient intakes, malnutrition in the elderly, the nutritional needs in pregnant women, poor nutrient intakes in low-income children, the iron needs of infants after 6 months, and the prevention of disease. Although there are situations where the use of vitamin and mineral supplements can improve the health of certain individuals, the consumption of conventional foods continues to be the preferred method to improve nutritional and health status. Under normal circumstances, individuals need the protein, carbohydrate, fat and calories, as well as vitamins and minerals, that food provides. Current U.S. Dietary Guidelines continue to suggest that consumption of these nutrients in conventional foods is the preferred form of intake. The U.S. Department of Agriculture (USDA) has long held that vitamin and mineral products serve as supplements to food and, therefore, are not part of the Food Stamp Program, which was designed to provide nourishment in the form of food. A 1999 USDA congressionally-mandated report indicated, that, on balance, food is the preferred way for nutrients to be consumed. The report addressed a number of issues low-income populations might face, if food stamps were used to purchase vitamin and mineral supplements. Congress faces several issues in considering this dietary supplement proposal in the future. Although some low-income households could surely benefit from appropriate use of vitamin and mineral supplements, allowing dietary supplements to be purchased with food stamps represents a fundamental change in the program’s original intent, which was to provide additional resources to purchase food. Currently, food stamp recipients have a minimum amount of benefits with which to buy foods needed for an adequate diet and none of the bills proposed so far would have provided any additional moneys to purchase dietary supplements. Individuals need the calories, macronutrients, vitamins and minerals that conventional foods provide, while dietary supplements provide only vitamins and minerals, without any food value. The provision allowed only for the purchase of vitamins and minerals, yet at a practical level, these products are difficult to separate from those containing herbs and botanicals. Certain administrative issues also would need to be resolved, some of which would have been addressed by the study that would have been required by the Senate’s version of the farm bill. This report will be updated upon further action on this issue. Contents Bills Introduced Since 1994 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Current Nutritional Status of the U.S. Population . . . . . . . . . . . . . . . . . . . . . 2 Dietary Patterns and Nutrient Intakes . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Pregnant Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Folic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Iron Intakes in Infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Low-Income Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Vitamins and Minerals and Disease Prevention . . . . . . . . . . . . . . . . . . 7 USDA Views on Purchasing Supplements with Food Stamps . . . . . . . . . . . 8 Support for Supplement Purchase with Food Stamps . . . . . . . . . . . . . . . . . 10 Issues Raised by Legislative Proposals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Dietary Supplements: Purchase with Food Stamps Since 1994, bills have been introduced in several Congresses that would allow dietary supplements to be added to the list of items that can be purchased with food stamps. Most recently, the Senate adopted language as part of the farm bill that would have allowed food stamps to be used to purchase dietary supplements of vitamins and minerals; this provision was dropped in conference with the House. This report examines the dietary supplement provisions of the 2002 Senate-passed farm bill, relevant nutrition issues, and specific issues regarding the purchase of supplements with food stamps. Bills Introduced Since 1994 Since 1994, nine bills have been introduced that would allow food stamps to be used to purchase dietary supplements of vitamins and minerals. The first bill (H.R. 5219) was introduced in the 103rd Congress by Congressman Emerson. During the 104th Congress, Mr. Emerson introduced two bills, H.R. 236 and H.R. 1997, which contained the dietary supplement provision. The House Committee on Agriculture held a hearing, and an amended bill was reported by voice vote and sent to the full committee for further consideration. However, the supplement provision received unfavorable comment from USDA and no further action was taken. In the same Congress, Senators McConnell and Hatch introduced similar language in S. 1133 and S.1143, respectively. In the 106th Congress, companion bills were introduced as H.R. 3304 by Representative Burton and S. 1307 by Senator Harkin, but they received no action. The dietary supplement language has been essentially identical in all the bills introduced in past Congresses. Most bills in the 103rd-106th Congresses consisted of a single provision that would have amended Section 3 of the Food Stamp Act of 1977, by adding nutritional supplements of vitamins, minerals or vitamins and minerals to the list of items that could be purchased with food stamps. The bill introduced by Senator Hatch in the 104th Congress (S. 1143) would have added dietary supplements, as they are defined under the provisions of the Federal Food, Drug and Cosmetic Act, to the items allowed on the purchase list. The manner in which these proposals use the term “dietary supplement” is significant. Nutritional supplements of vitamins, minerals or combinations are, at least theoretically, limited to only nutrients classified as vitamins or minerals. In contrast, the Dietary Supplement Health and Education Act of 1994 (P.L. 103-417, which amended the Federal Food, Drug and Cosmetic Act), defined the term ‘dietary supplement’ to include a product (other than tobacco) added to the total diet that contains at least one of the following ingredients: a vitamin, mineral, herb or botanical, amino acid, another dietary substance for use to supplement the diet, or a concentrate, metabolite, constituent, extract, or combination of any ingredients described above. Use of the CRS-2 term “dietary supplement,” without qualifications for only vitamins and minerals, would have expanded significantly the number of products that would qualify for purchase with food stamps. In the 107th Congress, the provision passed by the Senate to allow dietary supplements to be purchased with food stamps, as part of Food Stamp Program (FSP) reauthorization in the farm bill, was originally introduced as S. 1628 by Senator Harkin. The language was later adopted into the farm bill, the Agriculture, Conservation and Rural Enhancement Act, S. 1731, and passed by the Senate on February 13, 2002. Comparable language regarding supplements was not included in the House-passed version of the bill, so the supplement provision had to be addressed in conference. The vitamin and mineral supplements provision was not adopted by the House-Senate conferees in the final farm bill that passed both chambers in May 2002. The Senate-passed provision differed from the previously introduced language by specifying that products allowed to be purchased with food stamps include dietary supplements that provide exclusively one or more vitamins or minerals. It also required that an impact study be undertaken under a contract between the Secretary of Agriculture and a scientific organization to examine and report on the technical issues, economic impacts and health effects associated with allowing individuals to use food stamp benefits to purchase vitamin-mineral supplements. The study, which was to be completed within 2 years at an authorized appropriation level of $3 million, was to have addressed the following issues: ! the extent to which problems arise in the purchase of the supplements with electronic benefit transfer cards; ! the extent of difficulties in distinguishing vitamin-mineral supplements from ! ! ! ! herbal and botanical supplements for which food stamp benefits could not be used; whether participants in the FSP spend more on vitamin-mineral supplements than nonparticipants; the extent to which supplements are substituted for other foods purchased with food stamp benefits; the proportion of the average food stamp allotment that is used to purchase supplements; and the extent to which the quality of the diets of participants in the FSP changes as a result of allowing participants to use food stamp benefits to purchase supplements. Current Nutritional Status of the U.S. Population The proposals to allow food stamps to be used to buy dietary supplements are based on a number of assumptions about the nutritional status of the U.S. population. There are a variety of views on the possible ways in which the nutritional status of some individuals, particularly those in high-risk groups, might be improved, and whether a diet that includes supplements will provide those benefits. Dietary Patterns and Nutrient Intakes. Concerns are frequently raised that the dietary intake of many Americans is not nutritionally sufficient to fully meet the CRS-3 Recommended Dietary Allowances (RDAs) for vitamins and minerals. The RDAs are the levels of intake of essential nutrients that, on the basis of scientific studies, are judged by the National Research Council’s Food and Nutrition Board to adequately meet the known nutrient needs of practically all healthy individuals.1 The levels were set to provide a safety factor appropriate for each nutrient, and they generally exceed the actual requirements of most individuals, whose individual nutrient needs vary. The nutritional needs of most individuals will be met, by definition, even when their nutrient intakes fall somewhat below the RDAs. When planning meals, it is both technically difficult and biologically unnecessary to design a single day's diet that contains 100% of the RDAs for all nutrients. RDAs are goals to be attained over time, with a frequency of at least every 3 days for nutrients that turn over rapidly in the body and as much as a month for nutrients that are metabolized more slowly. U.S. survey data indicate that the majority of Americans do not have nutrient intakes that meet the RDAs for most vitamins and minerals. However, several unresolved issues have been raised about the data on nutrient intake in relation to the RDA standards. The survey data may underestimate the actual food consumed, and as a result, individuals may be consuming adequate amounts that are not accurately reported. A 1993 General Accounting Office report raised concerns about the quality of the nutrient composition tables that are used to determine intakes.2 Another longstanding issue concerns the minimum level of intake when it is less than 100% of the RDA for a given nutrient. Health professionals have not yet determined when the intake level of a given nutrient becomes problematic, such that individuals may become malnourished and health problems will result. Health data do not indicate that most Americans suffer from significant nutrient deficiency problems, even though they may not be reaching the optimal nutrient intake levels, according to food consumption reports. Controversy over the levels at which the RDAs have been set and whether they need to be revised is an on-going debate.3 The hunger advocacy community has raised concerns that RDAs are considered minimum levels, especially in the “thrifty food plan” which serves as the basis for setting food stamp benefit levels, and as such are inadequate for those who are truly dependent on food assistance programs for meeting their long-term nutritional needs. Others are concerned that the current RDA levels may be inadequate, given current nutrition knowledge, to provide the preventive effect of specific vitamins and minerals against certain chronic diseases. Some health professionals have questioned whether the RDAs are set too high, given that nutrient deficiencies are rarely observed in the general population, despite the fact that when surveyed, individuals report that they are not consuming the RDA 1 National Research Council. Recommended Dietary Allowances. 10th ed. Subcommittee on the Tenth Edition of the RDA, Food and Nutrition Board, Commission on Life Sciences. National Academy Press, Washington, D.C., 1989. 285p. 2 U.S. General Accounting Office. Better Guidance Needed to Improve Reliability of USDA's Food Composition Data. Report to the Chairman, Committee on Science, Space and Technology. House of Representatives. GAO/RCED-94-30, October 1993. 24 p. 3 Institute of Medicine. How Should the Recommended Dietary Allowances Be Revised? Food and Nutrition Board. National Academy Press, Washington, D.C., 1994. 36 p. CRS-4 levels for most nutrients. In response to these concerns, the Institute of Medicine (IOM) in 1994 began an effort to revise the nutrient standards. To date, the reference dietary intake (RDIs) reports have been completed for vitamins, minerals, and fiber as well as applications of RDIs for dietary assessment and establishing safe upper levels for nutrients. Revised assessments for the macronutrients (protein, carbohydrates, and fats) and the electrolytes are currently underway. The reference dietary intakes are the new term being used to replace the old RDAs, which were a single number for each age and sex group. The new RDIs provide multiple numbers for each nutrient to serve various uses. Elderly. Frequently, the elderly fail to achieve adequate nutrient intakes from their diet alone. As a group, the elderly experience a plethora of problems that influence their overall nutrient intakes. Their nutritional status can be influenced by inappropriate food intake, poverty, social isolation, dependence/disability, acute/chronic diseases or conditions, chronic medication use and advanced age.4 While some of these problems can be easily alleviated by dietary supplements, it is also true that the elderly generally need the calories, macronutrients and bulk provided by conventional foods. For a variety of reasons, eligible elderly are less likely to participate in the Food Stamp Program than other eligible groups, thus reducing the potential benefit of supplement purchase by food stamps for this age group. Forgetting to eat and take medications is a frequent problem among the elderly, which generally calls for some type of support system to assure that they meet their nutritional and pharmaceutical needs. Pregnant Women. Women who are pregnant have increased nutrient needs which are often not provided through dietary means alone. Women in their reproductive years constitute an at-risk group for nutritional inadequacies since their total caloric intakes tend to be low, at a time when certain nutrient needs are higher due to menstrual losses and increased requirements during pregnancy and lactation. Survey data indicate that when women's mean daily caloric intake was only around 1500 calories, their mean intakes for eight nutrients were above the RDAs (protein, vitamin A, ascorbic acid, thiamin, niacin, riboflavin, vitamin B12 and phosphorus), while their mean intakes for vitamin E, calcium, magnesium, vitamin B6, iron, zinc, and folacin were below the RDAs.5 Men consuming a mean daily caloric intake of 2800 calories had nutrient intakes equal to 98% or more of the RDAs for all but four nutrients. The major reason that the diets of women are relatively lower in nutrients is due to their lower total caloric intake. During pregnancy, RDAs are somewhat greater for most nutrients. An Institute of Medicine committee report concluded, that while the nutrient needs of pregnant women are particularly high, it was reasonably 4 Nutrition Screening Initiative. Incorporating nutrition screening and interventions into medical practice. Joint Effort of the American Academy of Family Physicians, the American Dietetic Association and the National Council on the Aging, Inc., Washington, D.C., 1994. 73 p. 5 National Research Council. Diet and Health: Implication for Reducing Chronic Disease Risk. Committee on Diet and Health. Food and Nutrition Board. National Academy Press, Washington, D.C., 1989. 749 p. CRS-5 easy for them to obtain the necessary amounts needed through dietary intake of food.6 Folic Acid. Scientific research suggests that nutritional supplements that contain folic acid may prevent the majority of neural tube birth defects (NTDs) in newborns. There are about 2,500 NTD births in the United States annually and therefore, it is recognized as a special problem related to pregnant women. The causes of NTDs remain unknown, but the increased risk of recurrence suggests at least some genetic component.7 Environmental factors are believed to play a role, especially in areas of high prevalence rates. Nutrient deficiency, particularly of folic acid, has been associated with NTDs, since a lower rate of recurrence has been seen in women taking folic acid supplements prior to conception. However, folic acid is primarily needed during the early weeks of pregnancy, at a time when most women are often unaware that they are pregnant. According to an IOM report, 50% of all pregnancies in the United States were unintended at the time of conception (defined as a mistimed or an unwanted pregnancy).8 In 1991 the Public Health Service (PHS) recommended that all women of childbearing age who are capable of becoming pregnant should consume 0.4 mg of folic acid per day for the purpose of reducing their risk of NTDs.9 However, PHS cautioned that, because the effects of high folic acid intakes are not well known, and complications in diagnosing vitamin B12 deficiency may occur, women should be careful that their total folate intake is less than one milligram per day. According to PHS, the possibility of reducing the number of cases of NTDs in the United States by 50% through daily consumption of 0.4 mg of folic acid is an important opportunity. PHS suggested several approaches to improve the delivery of folic acid to the general population in the dosage recommended by: a) improved dietary habits; b) fortification of the U.S. food supply; and c) use of dietary supplements. PHS indicated that FDA should determine which approaches would best achieve the goal of increasing folic acid intake, while ensuring that potential risks of overconsumption do not occur. Following a review of these approaches, the FDA now allows dietary supplement manufacturers to make a health claim for the relationship between folic 6 Institute of Medicine. Nutrition During Pregnancy. Part II Nutrient Supplements. Subcommittee on Dietary Intake and Nutrient Supplements During Pregnancy. Committee on Nutritional Status During Pregnancy and Lactation. Food and Nutrition Board. National Academy Press, Washington, D.C., 1990. 468 p. 7 Oski, F. A., ed. Principles and Practice of Pediatrics. J .B. Lippincott Co., Philadelphia, PA, 1994. p. 270. 8 Institute of Medicine. The Best Intentions: Unintended Pregnancy and the Well-being of Children and Families. National Academy Press, Washington, D.C., 1995. 380 p. 9 U.S. Dept. of Health and Human Services. Recommendations for the Use of Folic Acid to Reduce the Number of Cases of Spina Bifida and Other Neural Tube Defects. Public Health Service. Centers for Disease Control. Morbidity and Mortality Weekly Report, v. 41, no. RR-14. September 7,1991. p.1-7. CRS-6 acid and NTDs on supplement products.10 In addition, the agency initiated rulemaking to require folic acid fortification in foods to assure that it reaches the entire population.11 The final rule requires the addition of folic acid to enriched grain products to insure that more folic acid is available in the food supply. This enrichment requirement should also help individuals who may need this vitamin and become pregnant, without realizing that their need for folic acid has increased.12 To date, however, the decrease in the incidence of NTDs has not occurred at the rate anticipated by the efforts to provide fortification and claims on supplement products. A recent scientific report suggested that a higher folate intake may be needed through either increased fortification or supplementation recommended to women who may become pregnant.13 Iron Intakes in Infants. Infants who fail to receive adequate intakes of iron in their diet can suffer from impaired mental and behavioral development. Because iron is stored in the body, normal term infants can maintain satisfactory levels of iron from breast milk during the first 3 months of life. However, from birth to 2 years of age infants who are not breastfed need bioavailable sources of iron, such as iron fortified foods, or iron supplements, which can be given beginning at age 6 months.14 Increasing scientific evidence suggests that impaired psychomotor development, intellectual performance, and changes in behavior can result from iron deficiency. However, the long-term significance of these changes has not been determined. Low-Income Children. Children from low-income families often fail to achieve their nutritional goals from diet alone. The Community Childhood Hunger Identification Project (CCHIP) surveyed childhood hunger in the United States for a decade. It defined hunger to be the mental and physical condition that results from not eating enough food due to insufficient economic, family or community resources. The national data derived from the CCHIP household survey – conducted in 21 sites across the country – indicated that about four million children under the age of 12 experienced hunger at some time during the previous year, and about nine million of 10 U.S. Dept. of Health and Human Services. Food and Drug Administration. Food Labeling; Health Claims and Label Statements: Folate and Neural Tube Defects. Final Rule. Federal Register 59, January 4, 1994. p. 433-437. 11 U.S. Dept. of Health and Human Services. Food and Drug Administration. Food Standards; Amendment of the Standards of Identity for Enriched Grain Products to Require Addition of Folic Acid. Proposed Rule, Federal Register 58. October 14, 1993. p. 5330553312. 12 U.S. Dept. of Health and Human Services. Food and Drug Administration. Food Standards; Amendment of the Standards of Identity for Enriched Grain Products to Require Addition of Folic Acid. Final Rule, Federal Register 61. March 5, 1996. p. 8781-8797. 13 Wald, N.J., M.R. Law, J.K. Morris and D.S. Wald. Quantifying the effect of folic acid. The Lancet. V.358. December 15, 2001. P.2069-2073. 14 Institute of Medicine. Nutrition During Lactation. Subcommittee on Nutrition During Lactation, Committee on Nutritional Status During Pregnancy and Lactation. Food and Nutrition Board. National Academy Press, Washington, D.C., 1991. p. 159-160. CRS-7 them were at-risk of hunger during the same period.15 The survey also revealed that children from hungry families were more likely to experience unwanted weight loss, frequent headaches, fatigue, difficulty concentrating, anemia, asthma, allergies, diarrhea, frequent colds, and ear infections. Moreover, these children were more likely than others to be absent from school. An analysis of federal data revealed that participation in the FSP can improve the nutritional adequacy of the diets of poor children.16 For children whose households received food stamps, their diets were significantly better for 10 of 16 nutrients analyzed compared to the nutrient intakes of nonparticipating children. For most major nutrients, the proportion of poor children with serious dietary deficiencies drops significantly and their nutrient intakes increase when their households receive food stamps. These results are particularly important given the emerging evidence that even mild-to-moderate undernutrition in young children can lead to long-term, irreparable impairment in cognitive development and academic achievement. These data clearly indicate that adequate calories, along with adequate nutrient intakes, are important for low-income children. There is no evidence to suggest that the use of dietary supplements alone could provide the nutrient needs of these children to avoid health problems and maximize their learning potential in school. Vitamins and Minerals and Disease Prevention. Scientific evidence continues to support the position of dietary supplement advocates that increasing consumption of specific nutrients over an extended period of time may offer some protection against certain diseases or conditions, such as osteoporosis, cataracts, cancer and heart disease. Since 1980, dietary recommendations for the general public have been published by a number of federal agencies, private health organizations and consumer groups. All dietary guidance materials have been designed to provide consumers with information on how to select foods that are more healthful. However, the research data which support these recommendations primarily indicate that nutrients in the context of foods in the total diet have a greater impact on an individual’s health. The scientific evidence behind these recommendations clearly indicates that foods, rather than supplements, are the preferred source of the nutrients needed to protect against such chronic diseases as cancer, heart disease and osteoporosis.17 The most recent version of the Dietary Guidelines for Americans suggests that there may be situations in which certain individuals need a vitaminmineral supplement to meet a specific nutrient need. However, the Guidelines 15 Food Research and Action Center. Community Childhood Hunger Identification Project. A Survey of Childhood Hunger in the United States. Executive Summary, Washington, D.C., July 20,1995. 20 p. 16 Cook, J. T., L. P. Sherman, and J. L. Brown. Impact of Food Stamps on the Dietary Adequacy of Poor Children. Center for Hunger and Poverty and Nutrition Policy. Tufts University School of Nutrition, Boston, Mass., June 1995. 22 p. 17 U.S. National Research Council. Diet and Health: Implications for Reducing Chronic Disease Risk. Committee on Diet and Health. Food and Nutrition Board. Commission on Life Sciences. National Academy Press, Washington, D.C., 1989. 749 p. CRS-8 caution against large amounts of individual nutrients, herbal products, and supplement dependence to meet normal dietary needs.18 USDA Views on Purchasing Supplements with Food Stamps For years the Department of Agriculture has held the view that vitamin and mineral supplements are merely therapeutic agents and, as such, should not be eligible for purchase with food stamp benefits. (Likewise, the benefit under the Special Supplemental Nutrition Program for Women, Infant and Children, or WIC, does not include dietary supplements). The Food and Nutrition Service (FNS) Instruction 230(G)(1)[1985] states: Vitamins and Minerals. Vitamins and minerals which are marketed in various forms, such as tablets, capsules, powders and liquids, serve as supplements to food and food products rather than as foods and, therefore, are not eligible for purchase with food coupons. Vitamins and minerals are also present in natural foodstuffs, and certain vitamins and minerals have been determined to be essential to nutrition. However, because these essential vitamins and minerals occur naturally in foods, a good diet will include a variety of foods that together will supply all nutrients needed. Therefore, a nutritionally adequate diet may be obtained without the use of specially formulated vitamin and mineral preparations and other specially formulated therapeutic products. Since these products serve as deficiency correctors or therapeutic agents to supplement diets deficient in essential nutrition rather than as foods, they are not eligible for purchase with food coupons. . . . Benefits received under the FSP are based on sample food plans that have been constructed for recipients taking into account the RDAs for essential nutrients and food costs. The RDAs are considered to be adequate to provide acceptable levels of nutrients for low income households. The FY1995 USDA appropriations report directed the Department to prepare, by January 1, 1995, an analysis of allowing folic acid supplements to be purchased with food stamps, including the regulatory and legislative changes that might be required. Although a draft report was prepared outlining the Department's concerns about the use of food stamps to purchase folate,19 it was never released for publication or sent to Congress. In the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-93), Congress directed the Secretary of Agriculture to conduct a study, in consultation with the National Academy of Sciences and the Centers for Disease Control and Prevention, on the use of food stamps to purchase dietary supplements. The USDA report, transmitted to Congress, reviewed several issues related to low-income populations, including: nutritional status, potential supplement 18 U.S. Departments of Agriculture, and Health and Human Services. Nutrition and Your Health: Dietary Guidelines For Americans. Fifth Edition 2000, Home and Garden Bulletin, no. 232. 19 Personal Communication with Eileen Kennedy, Executive Director, U.S. Dept. of Agriculture. Center for Nutrition Policy and Promotion. May 10, 1995. CRS-9 value, supplement use patterns and expenditures, cost of commercial supplements, impact on food expenditures and agricultural commodities, administrative implications for the FSP and use of food stamps to purchase vitamin and mineral supplements.20 According to the USDA report, consumption of vitamins and minerals from food differs very little across income levels. Within low-income groups, food stamp recipients have better nutrient profiles than their non-participating counterparts. For some nutrients, the median intakes for food stamp recipients even exceed comparable averages for higher income individuals. Moreover, in terms of the quality of the diets, age and gender are more indicative: children have higher nutrient intakes than the general population, while females of child-bearing age, pregnant and lactating females, and the elderly have nutrient intakes below the recommended levels for more nutrients than the general population. Data on dietary supplement use from national surveys indicate that somewhere between 41% and 48% of the general U.S. population report that they take some type of vitamin and/or mineral products. The USDA report found that higher income individuals are more likely than low-income individuals to report the use of supplements, and among low-income persons, food stamp participants are less likely than non-participants to use supplements. Information on the use of dietary supplements by household is limited. Although there is general scientific consensus that dietary patterns and nutrient intakes can dramatically affect health, and a general understanding about the makeup of a healthy diet, the USDA report confirms that the link between diet and chronic degenerative disease is complex, and not yet well defined. While some research supports the use of dietary supplements in certain circumstances, the relative effectiveness of improved diet, fortified foods and supplement use varies across nutrients and subpopulation groups. The report also noted that current scientific knowledge was particularly limited on the contribution some non-nutrient components of food make in reducing disease; the differences in the bioavailability of nutrients in food compared to supplements; the nutrient levels that represent deficient and excessive intakes for certain nutrients and subpopulation groups; and the important interactions between different nutrient combinations. The average cost of commercially available vitamin and mineral supplements per tablet typically falls below 10 cents. It is generally expected that households with low income should be responsible for a portion of their food costs, and it also has been argued that these households have incomes sufficient to afford the cost of supplements on their own. According to the USDA report, allowing individuals to use food stamps to buy supplements, without also increasing total household resources, is unlikely to lead to greater spending on supplements and food, or to any improvement in their health and nutritional status. 20 USDA. Food and Nutrition Service. The Use of Food Stamps to Purchase Vitamin and Mineral Supplements. September 1999. 194 p. CRS-10 The USDA report also identified several administrative concerns for the FSP, if benefits were used to purchase supplements. For example, the Department would need to define which supplements are eligible for purchase with food stamp benefits; deal with the challenges of monitoring and enforcement; and determine whether the existing thrifty food plan adequately defines a healthful diet. In addition, consumer information would have to be provided so that food stamp recipients would know which dietary supplements to purchase in order to meet their individual needs and receive good value. Under current law, USDA is responsible for the Food Stamp Program, while the Food and Drug Administration is the agency responsible for the regulation of vitamin and mineral supplements. The Dietary Supplement Health and Education Act of 1994 (DSHEA, P.L.103-417) required a number of changes in the regulation of supplement products (see CRS Report RL30887, Dietary Supplements: Legislative and Regulatory Status, by Donna Porter). With the exception of rules governing good manufacturing practices, all regulatory provisions of DSHEA have been implemented. FDA continues to grapple, however, with issues related to supplement safety, claims, good manufacturing practices, and the reporting of side effects. Support for Supplement Purchase with Food Stamps In the decade during which these provisions have been introduced, Congressional sponsors have repeatedly held the view that food stamp recipients should be afforded greater flexibility to balance their diets by permitting food stamp purchases of vitamin and mineral supplements. Further they have stated that while it is possible to receive optimum levels of nutrients through a careful selection of foods, most people do not make these choices and enactment of the proposal could improve the nutrition and health of a segment of society that frequently falls below adequate levels of nutrient consumption. Since millions of Americans take vitamin and mineral supplements regularly to assure that they receive appropriate levels of these essential nutrients, sponsors believe that food stamp recipients should be afforded the same opportunity. Freedom of choice and the inconsistency of allowing food stamps to be used for non-nutritious or minimally nutritious foods, while excluding the purchase of nutritional supplements have been recurring themes. Members of Congress have viewed this legislation as a way to assist the poor who need the most nutritional help, especially those at high risk, women of child-bearing age, young children, and the elderly. In their view a positive contribution to public health can be achieved through permitting low-income Americans access to vitamin and mineral supplements through the Food Stamp Program. The Council for Responsible Nutrition (CRN), a Washington-based dietary supplement trade association representing ingredient supplier and manufacturers, has long supported use of food stamps to purchase dietary supplements of vitamins and minerals. In its position paper on this issue, the group cites specific statements in the U.S. Dietary Guidelines, USDA Human Nutrition Research Center on Aging at Tufts University, the NIH Consensus Development Panel on Osteoporosis and several well-known researchers who support its position on this issue. Those statements concern women of childbearing age taking folic acid supplements, individuals with little sun exposure needing vitamin D supplements, young children needing a CRS-11 multivitamin/mineral supplement for nutritional inadequacies, those who seldom eat dairy products needing calcium supplements, and vegetarians needing to take B12 supplements. CRN believes that food stamp recipients should not be prohibited from using their benefits to obtain vitamin and mineral supplements in these situations. Issues Raised by Legislative Proposals Under the Senate-passed farm bill, food stamp benefits would have been used to purchase dietary supplements of vitamins, minerals or combination supplements for the first time. This expanded use of FSP benefits would have been a fundamental departure from the original intent of the FSP, which was designed to deliver foods to low-income individuals by increasing their food purchasing power. However, supplementing a well-balanced meal with vitamin and mineral products was likely never envisioned by the original sponsors of the Food Stamp Act. Although dietary supplements can be a source of essential nutrients to aid in the prevention of disease and promotion of health, they cannot be a surrogate for the alleviation of “hunger,” which requires sufficient calories, carbohydrate, protein and fat. The FSP was designed to address food security by providing resources to enhance access to these macronutrients, and their associated calories, vitamins and minerals. In the debate over the use of food stamps for dietary supplements, a fundamental issue is the adequacy of the benefits currently provided. Participants are provided with a benefit package that is intended to enable them to obtain a nutritious diet through the purchase of low-cost foods. However, beneficiaries frequently report running out of food stamp benefits before the end of the month. In these situations, they have to make choices among the competing demands on their limited resources, (i.e., utilities, housing, health care, and food) or resort to emergency feeding services. The model food plans on which benefits are determined are reviewed periodically to be sure that they provide FSP participants with an adequate diet in the current economic environment. The food plans are criticized regularly by hunger advocates as inadequate to meet FSP participants' nutritional needs over the long period of time that they may be in the program. The latest revisions in 1999 sought to bring the thrifty food plan in line with current dietary patterns and food costs, a new market basket survey of food items, and menus and recipes that conform to the Dietary Guidelines. When the update was released, USDA indicated that current food stamp allotments were sufficient to purchase a nutritious diet that conformed to the Dietary Guidelines for Americans, the Recommended Dietary Allowances, and the serving recommendations of the Food Guide Pyramid.21 The dietary supplement provision passed by the Senate would not have provided additional benefits for the purchase of supplements. If supplements are covered under the FSP in future legislation without additional benefits authorized, the possibility exists that some individuals would not purchase the foodstuffs necessary to meet their nutritional needs. A related concern is the cost of nutrients consumed in the form of dietary supplements compared to conventional foods. 21 U.S. Department of Agriculture Center for Nutrition Policy and Promotion. Thrifty Food Plan, 1999. Administrative Report, CNPP-7. 136 p. CRS-12 Dietary supplements are considerably more costly in terms of the nutrients delivered, compared to foods, which can deliver not only vitamins and minerals, but also the macronutrients and calories the body needs. On the other hand, low-income households could benefit nutritionally if the dietary supplements provide 100% of the RDAs (national nutrient standards) for vitamins and minerals on a daily basis. Consumption of such a supplement – in addition to whatever foods are consumed – would assure that those who are more likely to be at nutritional risk would have adequate amounts of essential nutrients. However, many vitamin and/or mineral preparations contain only one or two nutrients and do not provide for a balanced intake of all the essential nutrients. The nutrients in these products frequently are in megadoses, i.e., the amount per tablet is considerably more than the national intake standard. Megadoses of vitamins and minerals can be toxic. They can also lead to secondary deficiencies in individuals who may already be suffering from inadequate intakes of certain trace vitamins and minerals. The issue of setting upper intake levels for nutrients has been addressed by a National Academy of Sciences - Institute of Medicine’s Food and Nutrition Board Committee, which established a risk assessment model.22 Many supplement products also contain vitamins and minerals in combination with a variety of other ingredients included in the broad definition of dietary supplements provided by DSHEA. Under this definition, any or all of these substances (most of which have not undergone any safety testing) could potentially be purchased with food stamps, if care is not taken at the time of purchase. The Senate supplement provision did not provide any limitations on the type or composition of supplements that could be purchased. While the bill language specified that the supplements purchased with food stamps had to be “exclusively” one or more vitamins or minerals – the Senate Committee on Agriculture report excluded herbals and botanicals – many supplement products with more than one ingredient also contain an herbal ingredient. The Senate provision also would have required a study to determine the impact of allowing dietary supplements to be purchased with food stamp benefits. The study was to examine the effect this change would have on the technical, economic and health aspects of the program and would have been conducted simultaneously with implementation of the provision. The study was to examine similar issues to those addressed in the 1999 USDA report transmitted by Congress. Should this proposal reemerge in a future piece of legislation, Congress might find it useful to have the results of such a study. Other options could include demonstration projects to determine: the administrative, financial, and nutritional ramifications of allowing supplements to be purchased with food stamp benefits; the need to educate food stamp beneficiaries or cashiers in stores where food stamps are accepted for supplements; and the feasibility of a computerized system in stores that would allow certain supplements to be purchased with food stamp benefits. 22 Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes: A Risk Assessment Model for Establishing Upper Intake Levels for Nutrients. 1998.