Dietary Supplements: Purchase with Food Stamps
Report for Congress
Dietary Supplements: Purchase with
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
Since 1994, nine bills have been introduced to allow dietary supplements to beth
purchased with food stamp benefits. In the 107 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.
Bills Introduced Since 1994......................................1
Current Nutritional Status of the U.S. Population.....................2
Dietary Patterns and Nutrient Intakes..........................2
Iron Intakes in Infants......................................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
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 billrd
(H.R. 5219) was introduced in the 103 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 billth
introduced by Senator Hatch in the 104 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
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
!whether participants in the FSP spend more on vitamin-mineral supplements
!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
!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
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
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
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.
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,4
acute/chronic diseases or conditions, chronic medication use and advanced age.
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
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.
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.
easy for them to obtain the necessary amounts needed through dietary intake of
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 at7
least some genetic component. 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.
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
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. 53305-
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.
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 vitamin-
mineral 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.
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) 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,
19 Personal Communication with Eileen Kennedy, Executive Director, U.S. Dept. of
Agriculture. Center for Nutrition Policy and Promotion. May 10, 1995.
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
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.
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
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
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.
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.