SNAP: The Supplemental Nutrition Assistance Program and Its Future

When we come home every evening to join our friends and families for dinner, many of us seldom worry about whether we will have food on the table. For millions of Americans, however, hunger is a very real difficulty as they struggle to feed both themselves and their children. As part of the effort to combat hunger in the United States, physicians should support the continued funding of SNAP, a program implemented by the federal government to answer the challenge of food insecurity.

Since the 1960s, the Supplemental Nutrition Assistance Program, or SNAP, has provided eligible, low-income individuals and families with benefits for food at eligible retail stores. Formerly known as food stamps, this federal program assisted nearly 45 million individuals in 2017, especially households with children, elderly, and disabled persons. Eligibility for SNAP is limited to people with gross incomes up to 130% of the federal poverty line. Families are provided with monthly electronic debit cards to purchase groceries at authorized retailers.

In 2015, SNAP helped 4.6 million Americans rise above the poverty line, including 2 million children. The program also reduced the prevalence of food insecurity by as much as 30%. It also supports the economy; for every $1 billion added to SNAP funding, approximately 18,000 new jobs are created.

Research by the USDA Economic Research Service has found strong correlations suggesting that food insecurity increases the risk of adverse health outcomes and leads to higher healthcare costs. In 2017, food-insecure households spent 45% more on medical care compared to food-secure households. These people had a higher prevalence of heart disease and diabetes, and were more likely to be non-adherent to their medications. Conversely, SNAP participants were healthier and incurred about $1,400 less in medical costs over a year than other low-income individuals. Additionally, children with access to SNAP have improved long-term health, with lower risks of obesity, heart disease, and diabetes.

While SNAP fights to ensure that no American goes hungry, it also encourages work through specific requirements for able-bodied adults without dependents, or ABAWDs. Through the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, non-disabled individuals between the ages of 18 and 49 can only get SNAP for 3 months in 36 months unless they work 80 hours per month, participate in a qualifying educational or training activity, or do unpaid work through special State-approved programs. While the USDA’s Food and Nutrition Service determines its broad policy, states and counties manage its daily activities and administration. Many states request federal permission to waive these time limits due to local economic difficulties. These waivers have been crucial in assisting individuals who live in areas of particular hardship.

Currently SNAP is facing significant changes to its funding and structure. President Trump’s 2019 budget proposes cutting SNAP funding by over $213 billion over the next 10 years and restructuring how benefits are delivered. At least 4 million people would lose eligibility, and many others will have reduced benefits.

The biggest change is that the government will stop its partnership with over 260,000 retail stores around the country and instead provide government-purchased food boxes of nonperishable goods. This would mean that families would have less choice in their food, especially with fresh fruits and vegetables. Also, the states would be left to determine how these food boxes would be distributed and bear its costs.

Furthermore, a portion of these SNAP benefits would be withheld from households, and would ultimately affect 34 million people, or almost 90% of SNAP participants, in 2019. The proposal would also limit waivers for ABAWDs and increase the maximum age, which would severely impact those in high-unemployment areas, the elderly, and the disabled. Additionally, SNAP nutrition education funding would be eliminated, which would severely hinder the program’s goals for improved nutrition.

Proponents of these changes suggest that this will be an effective method of cutting government spending, while providing standardized meals for families. Concerns exist that SNAP creates “food stamp dependency” and increases the risk of childless and disability-free adults relying solely on SNAP benefits instead of working. Some studies by organizations such as the Foundation for Government Accountability report that many ABAWDs who left these programs after certain states renewed these time limits found work within 12 months and experienced a significant increase in their income. However, many studies have found that most people continue to work while remaining on SNAP, and that these waiver restrictions mostly affect people who live in areas without any available work.

While managing government spending is a perpetual aim for every Congress and President, the proposed changes to SNAP have the potential to negatively affect millions of American families, especially children. There would likely be an increase in health-related problems for individuals of all ages who relied on these benefits, which would lead to an increase in healthcare costs. It would also undermine previous efforts at promoting healthy nutrition habits and education. Improving savings in the national budget is a worthy goal, but not at the expense of pushing millions of people closer to hunger.

As physicians, we should make every possible effort to protect families and children from hunger. Please contact your local and federal representatives and encourage them to continue SNAP funding without restructuring the program or withholding SNAP benefits from those in need of assistance.

Vishnu Prathap, MD


Archambault, Josh. “Restoring Work Requirements: An Important Fix To America’s Food Stamp Crisis.” Forbes, Forbes Magazine, 11 Aug. 2015,

Belluz, Julia. “45 Million Americans Rely on Food Stamps. Trump Wants to Gut the Program.” Vox, Vox, 23 May 2017,

Carlson, S, and B Keith-Jennings. “SNAP Is Linked with Improved Nutritional Outcomes and Lower Health Care Costs.” Center on Budget and Policy Priorities, 17 Jan. 2018,

Ingram, J, and N Horton. “How Kansas’ Welfare Reform Is Lifting Americans Out of Poverty Work.” The Foundation for Government Accountability, 16 Feb. 2016,

Office of Research and Analysis. “Food and Nutrition Service.”Food and Nutrition Service, United States Department of Agriculture, Apr. 2012.

Rector, Robert, and Vijay Menon. “SNAP Reform Act Offers Sound Basis for Welfare Policy.” The Heritage Foundation, 9 Jan. 2018,

Rosenbaum, D, et al. “President’s Budget Would Cut Food Assistance for Millions and Radically Restructure SNAP.” Center on Budget and Policy Priorities, 15 Feb. 2018,

“Supplemental Nutrition Assistance Program (SNAP): Able Bodied Adults Without Dependents.” Food and Nutrition Service, United States Department of Agriculture, 26 Feb. 2018,

“Understanding SNAP, the Supplemental Nutrition Assistance Program, Formerly Food Stamps.” Feeding America, 2018,


Cyberbullying: A Pediatrician’s Role in the Digital Age

Due to the recent explosion of hand-held technology over the past 2 decades, a new form of bullying has emerged called “Cyberbullying”. This type of bullying utilizes electronic means of communication such as text messaging, email, websites, or social media (Facebook, Twitter, etc.) to victimize and cause a power imbalance between peers. Pediatricians should identify signs of cyberbullying and provide appropriate anticipatory guidance and resources to both parents and patients.


Firearm Safety Considerations in the Pediatric Population

Recent tragedies in Las Vegas, Nevada, and Parkland, Florida have returned the topic of firearm safety to the forefront of societal and political discourse. Children and adolescents are particularly affected by firearm violence. The latest population data is sobering – nearly 12 firearm deaths per day in the United States in children ages 0-21 years old. The American Academy of Pediatrics (AAP) continues to call for legislative action to reduce the incidence of firearm-related violence. Initiatives championed by the AAP include: (1) banning assault-style weaponry, (2) banning Internet sale of firearms, and (3) requiring background checks prior to purchase of a firearm, to name a few.

How can pediatricians work to promote safety in their patient population? Efforts on both a political front through advocacy and on a personal scale via anticipatory guidance during well child examinations can create societal and individual change to improve the health and safety of all children.


  • Nearly 1 in 5 deaths in American youth under-20 is firearm-related.
  • Merely the presence of firearms in the home increases the risk of suicide among adolescents. The risk is even worse if the gun is kept loaded.
  • A study of personal firearm storage revealed:
    • 21.7% of subjects kept their firearms loaded when stored at home
    • 31.5% of subjects stored their firearms in unlocked locations
    • 8.3% of subjects kept their firearms loaded AND stored in unlocked locations
  • More than 75% of guns used in suicide attempts and unintentional injures of children ages 0-19 were stored in the residence of the victim, a relative, or a friend.
  • Children as young as 3-years old can produce enough squeezing pressure to pull a trigger on a loaded gun


  • The most effective measure to prevent firearm violence is the absence of firearms in the home.
  • Stricter regulations regarding access and purchasing of firearms
  • Better storage of weapons including trigger locks and locked storage boxes
  • Mechanistic alterations to make firing a weapon more difficult for children, such as increasing trigger pressures


  • Advocacy
    • Send correspondence to your local state legislator to share your views on firearm safety and the need for stricter control of access and storage
      • The AAP has resources to find the contact information for your state legislators and a draft email here.
    • Engage with local schools and media to offer your experience and expertise.
      • The AAP has developed talking points regarding firearm violence in the pediatric population that can be found here.
    • The AAP recommends pediatricians address firearm safety as part of routine anticipatory guidance for families with children of all ages.
  • Anticipatory Guidance
    • Always asked about firearms in the home. Where are they stored? Are they locked? Who has access?
    • Inform families that the safest homes are those without guns.
    • For homes with firearms, encourage families to take practice safe storage – store guns and ammunition separately and in locked containers.
    • Encourage removal of firearms in homes with adolescents, especially if there is a history of mood disorders, substance abuse and/or a history of suicide attempts.
    • Encourage parents to ask if there is a gun in the house before sending children to play at a friends’ home.

Firearm violence is a huge issue that will constantly provoke heated debate and passionate rhetoric from all sides. As pediatricians, we can take simple steps to inform parents and help protect the most vulnerable population of our society.

D. Alan Potts, MD



Implementing Perinatal Depression Screening into the WCC

Problem: Texas enacted House Bill 2466, effective September 1, 2017, to provide Medicaid and child health plan coverage for maternal depression screening during an office visit for the child.  The purpose of this brief report is to inform clinicians of this coverage and urge Pediatricians to standardize the practice of perinatal screening during well child checks in the first year. 

Background: One out of every seven women experience depression during pregnancy or within one year of delivery, defined as “perinatal depression”.  This staggering statistic makes perinatal depression the most underdiagnosed obstetric complication in the United States.  If untreated, perinatal depression can have devastating consequences for the mother, their child, and their families.  Research has shown a higher incidence and risk for preterm birth, low birth weight, intrauterine growth restriction, pre-eclampsia, substance use during pregnancy, suicidality and infanticide.

  • Prevalence of perinatal depression is 2x greater in low-income women
  • Perinatal depression can threaten the initial mother-child relationship – i.e. attachment, bonding, breastfeeding
  • Perinatal depression can negatively affect all aspects of a child’s development – lower level of engagement, lower activity level, poor regulation, withdrawal

Last year the U.S. Congress enacted the “21st Century Cures Act”, which included the “Bringing Postpartum Depression Out of the Shadows Act of 2015”.  This law established and expanded pre-existing state funding for maternal depression screening and treatment in primary care settings. The goal was to provide doctors with the training and resources to complete screening, as well provide the follow up support and treatment therapies necessary.

In response to the new federal law, Texas passed the House Bill 2466.  Texas’ new law directs the state agency to develop rules for implementing the maternal depression screening and provide Medicaid coverage for it, regardless of whether the mother is also a recipient of Medicaid.

For guidance, clinicians can review the work done by leaders in Massachusetts to identify women facing perinatal depression and engaging them in appropriate therapies.  The Massachusetts Child Psychiatry Access Project (MCPAP) for Moms developed as a spinoff program of the successful MCPAP launched in 2005.  The original MCPAP was designed to help pediatricians manage pediatric psychiatric needs.  MCPAP for Moms provides three main services:

  1. Trainings and toolkits to assist Pediatricians in depressing screening, referral, medication discussions, and other treatment options
  2. Real-time psychiatric telephone consultation for providers caring for pregnant and post-partum women
  3. Networking opportunities with community-based resources to support pregnant and post-partum women

Recommendations/Takehome points: As Pediatricians, we are often the first to see a mother after she leaves the hospital.  We have a unique and important opportunity to identify those struggling with perinatal depression, and get them the help they need and deserve quickly.

  • Perinatal depression screening can be appropriately integrated at the 1, 2, 4, and 6 month visits for the child.
  • It can be as simple as two questions:

Over the past 2 weeks:

(1) Have you ever felt down, depressed, or hopeless?

(2) Have you felt little interest or pleasure in doing things?

  • Screening does not require the Pediatrician to treat the mother. It gives an opportunity to refer her to the appropriate resources.

Alison Kimura, MD, MPH



  6. Byatt, Nancy, et al. “Improving perinatal depression care: the Massachusetts Child Psychiatry Access Project for Moms.” General hospital psychiatry40 (2016): 12-17.
  7. Earls, Marian F., and Committee on Psychosocial Aspects of Child and Family Health. “Incorporating recognition and management of perinatal and postpartum depression into pediatric practice.” Pediatrics5 (2010): 1032-1039.



Mental Health Screenings in Adolescent Care

The first week of October every year is designated as Mental Health Awareness Week in the United States – a pattern established by our Congress in 1990 to recognize the efforts of the National Alliance on Mental Illness (NAMI, and increase awareness about mental health conditions. As we close out the end of Mental Health Awareness Week, I would like to focus on an important topic that sometimes ends up being overlooked or rushed through at a primary care visit: mental health screenings in the adolescent population.

According to results derived from a recent National Comorbidity Survey Replication, nearly 50% of all mental health conditions in the United States begin by age 14. Per data from the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA), suicide is currently the second leading cause of death in adolescents; 18% of high school students nationwide reported having seriously considered attempting suicide (females > males), and at least 9% had attempted suicide one or more times. Identifying a possible mental health diagnosis early in life — such as depression, anxiety disorders, ADHD, eating disorders, or PTSD — can help save many individuals from life-altering consequences.

The American Academy of Pediatrics (AAP) recommends annual mental health screenings for adolescents starting at age 12. While state Medicaid provisions in Texas previously only allowed for one mental health screening, total, to be billed between the ages of 12 and 18 as part of an annual well-child exam, recent Texas legislation passed on September 1, 2017 (HB 1600) now allows Medicaid reimbursement for up to once-a-year mental health screenings with well-child exams from the ages of 12-18, which is an important step in the right direction.

Texas, however, is currently in the midst of a mental health workforce shortage, especially in child and adolescent psychiatry. Although legislative efforts to address this shortage within the state are in progress, it renders the pediatrician or primary care doctor’s duty to address mental health within adolescent well-child visits absolutely imperative at this moment.

Screening questions/tools that can be used in an adolescent primary care mental health screening can include, but are not limited to:

  • HEADDDSS Assessment:
    • Home – living situation, safety in the home, relationships with family
    • Education/Environment – address any learning/attention difficulties, friends and social circle, school and online bullying, social media (mis)use
    • Activities – hobbies, extracurriculars, jobs
    • Diet – include screening for disordered eating behaviors
    • Drugs:
      • Substance Use Screening Tool: CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble)
    • Depression/Suicidality:
      • Screening Tools: PHQ-2 (initial screen) + the more detailed PHQ-9
    • Sexual Activity/Sexuality/Sexual Abuse
  • Anxiety Screening Tool: SCARED (Screen for Child Anxiety-Related Emotional Disorders)
  • Trauma Screening Tool: CATS (Child-Adolescent Trauma Screen)
  • Pediatric Symptom Checklists (PSCs)

*Note: Mental health screenings for adolescents under Texas Medicaid must utilize at least 1 of the screening tools approved by Texas Health Steps, which includes the PSCs, the CRAFFT, and the PHQ-9.

For additional mental health information for patients, such as finding the closest behavioral health treatment centers, an excellent resource is the national SAMHSA website at

Anita Verma, MD

American Academy of Child and Adolescent Psychiatry. (2013). Child and Adolescent Psychiatry Workforce Crisis: Solutions to Improve Early Intervention and Access to Care.
American Academy of Pediatrics. (2017). Recommendations for Preventative Pediatric Health Care. Bright Futures, 4th Ed.‐us/documents/periodicity_schedule.pdf
Centers for Disease Control and Prevention. (2016). Children’s Mental Health Report. CDC Features: Life Stages and Populations.
Centers for Disease Control and Prevention. (2016). 1991-2015 High School Youth Risk Behavior Survey data.
Department of Health and Human Services, Office of Adolescent Health: Adolescent Mental Health Fact Sheets.
HB 1600: Relating to certain mental health screenings under the Texas Health Steps program.
Kessler R.C., et al. (2005). Lifetime Prevalence and Age of Onset Distributions of DSM‐IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 62(6): 593‐602.
Testimony of Pritesh Gandhi, MD, MPH, to the Texas House of Representatives Public Health Committee, in support of HB 1600, March 2017. Submitted on behalf of the Texas Pediatric Society, Texas Medical Association, and Texas Academy of Family Physicians.


Addressing Nutrition and Childhood Obesity at the Pediatrician’s Office

Childhood obesity is a growing problem that we are battling in the United States. According to data from the Centers for Disease Control and Prevention from 2011 to 2014, 12.7 million children and adolescents were obese in the United States, or every 1 in 6 children. Obesity has been shown to increase the risk of disease in multiple systems of the child’s body:

  • Insulin resistance and Type 2 Diabetes
  • Asthma, sleep apnea, and other respiratory conditions
  • Cardiovascular health- high blood pressure and high cholesterol
  • Musculoskeletal and joint problems
  • Fatty liver disease, gallstones, and heartburn

Furthermore, children with obesity are far more likely to grow up to be adults with obesity. Pediatricians need to vigilantly monitor and treat obesity early.

Identify the Problems at the Office

  • Review growth charts during every visit. Overweight is defined as a BMI between the 85th percentile and the 95th percentile for age and sex. Obesity is defined as a BMI at or above the 95th
  • Ask questions about exercise and nutrition:
    • How many meals a day and what kind of foods? How about snacks?
    • How many cups of juice a day? How about soda?
    • How many servings of fruits or vegetables a day?
    • How many hours of ‘screen time’ a day?
    • How many hours of physical activity a day?

What to Recommend

  • Studies have shown that addressing the issues of screen time, limiting sugary beverages, and increasing activity level are associated with a reduction in BMI.
  • Set goals with advice for your patient, 1 or 2 a visit, for example:
    • Control portion sizes: 3 meals and 2 healthy snacks a day and make half the plate fruits and veggies.
    • Encourage water drinking. Limit juice per day to 4 oz for ages 1-3 yrs, 4-6 oz for ages 4-6 yrs, and 8 oz for ages 7-18 yrs.
    • Encourage at least 5 servings of fruits and vegetables a day. Children can participate by helping to choose fruits or veggies to eat for meal or snack.
    • Limit screen time to 2 hours a day. Remove televisions from the bedrooms and turn off screens during meal times.
    • 60 minutes of physical activity a day. You can take your child to the park every day.


Resources and Recipes for Families


  6. Perrin EM, Finkle JP, Benjamin JT. Obesity prevention and the primary care pediatrician’s office. Current opinion in pediatrics. 2007;19(3):354-361. doi:10.1097/MOP.0b013e328151c3e9.

Jennifer Ni, MD

CHIP Re-Authorization

On September 30 of this year congress must act on whether or not CHIP (Children’s Health Insurance Plan) is to be refunded!

What is CHIP?

CHIP is a mostly federally funded insurance program (about 87% federally funded) that provides coverage to over 9 million children in the United States. It is primarily intended for families in the lower to middle classes, meaning those who make enough income to not qualify for Medicaid, but would likely have difficulty affording private insurance. Thus, it is reasonable to assume that if CHIP were to have dramatic alterations that affect its reach that children who would lose coverage or move to an ineffectively expensive model would suffer. CHIP was founded in 1997, at which time 13.9% of American children were uninsured. This number has subsequently decreased to less than 5%.

I, amongst many others, believe it is imperative that congress passes a clean CHIP bill to allow for continued federal funding of CHIP without a significant amount of add-on clauses that would limit its reach. I can think of a multitude of scenarios directly from clinical experience where this would benefit children of lower to middle class families. We frequently encounter young patients with chronic illnesses in everyday practice that would greatly benefit from continuing CHIP. One example of a chronic illness would be asthma. Many families having children inflicted with this illness are covered by CHIP. When severe this tends to result in multiple hospitalizations, ICU stays or even death. These unfortunate outcomes are frequently avoided by dutiful use of prescription medications prescribed on an outpatient basis. Once asthma is staged as more severe, it requires more medication, which ultimately may be unaffordable on a private health insurance plan. If a family, who did not qualify for Medicaid, were to be denied CHIP, I can envision a scenario where many families would not be able to attain the appropriate medications. I can only imagine that this would continue to be a problem and would lead to further complications that may be avoidable.

If funding is not renewed, 31 states would completely run out of the federal funds provided for CHIP by March 2018 with Texas estimated to run out of funding in April 2018. This is an unpalatable fact for the current pediatric patients crucially supported by this program. Please write your local/federal representatives and encourage them to vote for re-funding CHIP without alterations.

Sam Hankins, MD

September 20, 2017



Promoting Physical Activity in Children: The role of a Pediatrician

Almost everyone, especially medical professionals, would agree that getting regular exercise is good for your health. Many studies have shown that regular exercise decreases the risk of cancer, heart disease, and premature death in general. In children, increased physical activity has been linked to better performance in school. Despite the clear benefits of physical activity on health and other outcomes, few patients report receiving physical activity counseling from their primary care physician. As physicians and leaders in the community, pediatricians should provide appropriate physical activity counseling to their patients, as well support efforts to better assess and address obstacles to regular physical activity in the pediatric population. (more…)

Renewed National Support for Pediatric Cancer Research

When I was in the third grade, my classmate, Jennifer, passed away. It was 1996, and for the past three years, she had fought an uncommon form of leukemia. In the end, she did not live to see her 10th birthday. Each year, over ten thousand children below the age of 19 in the United States will be diagnosed with some form of cancer. Jennifer was by no means alone in her struggle.

The good news is that more and more of these children are becoming success stories. While in 1960, only five percent of children with cancer survived longer than five years, that number has since skyrocketed to over eighty percent. This is excellent news! But as 1,200 children will suffer the same fate as Jennifer in 2017, we must continue to strive to improve our ability to treat and cure cancer.

As pediatricians, we have a responsibility to encourage Congress to increase federal support for pediatric cancer research. Bill HR 820 was introduced in the House by Representative Michael McCaul on 2/2/17, and seeks to “maximize discovery and accelerate development and availability, of promising childhood cancer treatments.” Known as the Childhood Cancer STAR (Survivorship, Treatment, Access, and Research) Act of 2017, this bill seeks to help research efforts through a variety of different ways. First, through the continued and expanded establishment of cancer biorepositories, that researchers would be able to access and study in a laboratory setting. This is an obvious first step, and one that we welcome as an extension of the NIH funding already afforded to research in pediatric oncology.

Second, and critically, the bill amends the Public Health Service Act to state that there must be a pediatric oncologist on the National Cancer Advisory Board, to better advocate for our pediatric patients at the national level.

Additionally, the act sets forth several sections focused on the research of late effects of childhood cancer—an important inclusion, as there will be over 500,000 pediatric cancer survivors by the year 2020. We cannot afford to ignore this population, as well as their impact on the health care system in the future. Similarly, the bill seeks to establish cancer survivorship programs, and offer grants to improve follow-up medical and psychiatric care.

These are all worthy goals, and we will be closely monitoring the progress of this bill. Currently it is in the Subcommittee on Health, but we hope that it will move forward, for the good of all pediatric cancer patients in our country. It is encouraging to see legislation that so directly advocates for children in America.

See the bill here:


Other Sources:


Call for comments to help FDA with providing nutrition facts to consumers.

An average American is approximately 15 pounds heavier compared to 20 years ago. Height, however, has stayed relatively constant, meaning that our BMI’s are increasing. Unfortunately, children are not immune to this observation. An average 11 year old female has gained more than 11 pounds, and an average 11 year old male has gained more than 13.5 pounds over the past 20 years, leading to the “childhood obesity epidemic” we often hear about in the media. To combat the skyrocketing weight trend, we should write comments to help pass regulations which will increase consumer awareness of various foods’ nutritional values. (more…)