In an exploratory analysis including a subsample of states with complete data, we also examined whether changes in WIC-participating children’s birth weight and maternal BMI were confounders. 12 To reduce confounding from other concurrent trends, such as the Great Recession of 2007 to 2009, which occurred during a similar time period as the package change and which resulted in an increase in the use of federal food assistance and new populations using such assistance, we controlled for changes in racial-ethnic composition and child poverty at the state level. 11 In this study, we compared population trends in obesity prevalence among WIC-participating 2- to 4-year-olds before and after 2009 to estimate whether there were changes in obesity prevalence or changes in the trend in obesity prevalence that may be attributable to the package change. In interrupted time-series analysis, regression models estimate trends in population measures of an outcome before a prespecified time when a policy change (or other intervention) occurs and then test whether the trend changes afterward. This quasi-experimental study employed interrupted time-series analysis 11 by using repeated cross-sectional measurements of obesity prevalence among WIC-participating children at the state level to test the potential impact of the 2009 WIC package change on childhood obesity trends. 10 In this article, we evaluate whether national and state-level trends in obesity prevalence among WIC-participating 2- to 4-year-old children changed after the 2009 WIC package revision, adjusting for sociodemographic composition and other risk factors for childhood obesity.

A focus on state-level trends is particularly important given the level of control that state WIC agencies have over program administration 1 states had discretion for implementing certain aspects of the revised food packages and may have differed in the extent to which healthier foods were made available. 8 Given the variation in childhood obesity rates by state, 9 evaluating longer-term trends in obesity prevalence and the potential differential impact of the WIC package change by state is critical. The Centers for Disease Control and Prevention (CDC) reported a decline in the prevalence of obesity and severe obesity among WIC-participating children from 2010 to 2014 but did not directly test whether the WIC package change was associated with a change in childhood obesity trends. On the basis of these well-documented improvements in nutrition after the WIC package change, the risk of childhood obesity among WIC-participating children may also have declined.

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