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Missouri was one of 31 states that recorded modest decreases in obesity among young children following changes to a federal health program, Centers for Disease Control and Prevention data show.

Revisions that the U.S. Special Supplemental Nutrition Program for Women, Infants and Children (WIC) made to its food package program in 2009 played a role in stopping a rise in obesity of children ages 2-4, and possibly reducing obesity in some, data show.

WIC is a supplemental nutrition program that provides services to pregnant women, new mothers, infants and children up to their fifth birthday, based on nutritional risk and income eligibility. The program provides primarily health screenings, risk assessments, nutrition education and counseling, breastfeeding promotion and referrals to health care.

In addition to being at-risk for poor nutritional status, WIC-eligible children have been vulnerable to childhood obesity, according to the academy.

Studies conducted by the CDC and by the American Academy of Pediatrics find similar conclusions — that changes to the WIC food package had a positive effect.

"We hypothesized that the food package change reduced obesity among children participating in WIC, a population that has been especially vulnerable to the childhood obesity epidemic," the academy's report states.

Before the change, the prevalence of obesity among 2- to 4-year-old WIC participants across the United States was increasing by about a quarter of a percentage point annually, the academy reported. However, changes in social or demographic factors did not appear to be connected to the growth.

Even locally, specific changes to the program may correlate to lower cases of obesity in very young children, said Melinda Ridenhour, director of the Cole County WIC program.

"The addition to the food package of fruits, veggies and whole grains, as well as the decrease in the amount of juice that was previously provided all have positive correlations with healthy body weight," Ridenhour said. "There is a strong correlation between obesity and increased intake of sugary beverages (including juice) and low intake of fruits, veggies and whole grains."

Lisa Cox, the Missouri Department of Health and Senior Services chief of public information, said increased choices for foods in the package, including cultural food options, have improved overall nutrition quality.

"Participants may request soy milk or tofu be substituted as a milk (dairy) option. In 2015, participants were able to get yogurt as a substitute for milk or cheese," Cox said.

To be eligible for the WIC program, recipients must have an income that is equal to or less than 185 percent of the poverty level and must have been determined by a health professional to be at nutritional risk.

According to the U.S. Department of Health and Human Services, the poverty level for a single person in a home is $12,140; for a two-person household is $16,460; for a three-person household is $20,780. For each additional person in a household, the income increases by $4,320.

The WIC program provides vouchers for nutrient-dense foods and beverages to more than half of all U.S. infants.

Going into 2009, foods that could be bought through the program included milk, cheese, beans, peanut butter, eggs, juice, cereal and grains. The changed program provided extra cash allowances for fruits and vegetables and reduced the packaged juice allowance by half. It requires whole-grain instead of refined grain products, and low-fat or skim milk for the young children. It reduces cheese, according to the academy.

"Due to their nutrient and fiber content, these foods are shown to help people in maintaining a healthy body weight. WIC dietitians in my office counsel clients on decreasing sugary beverages and increasing water, fruit, vegetables and whole grains," Ridenhour said. "It's helpful that that foods provided line up with the education provided."

Data suggest the revised WIC package has positively affected household diets, which in turn has created improvements to Healthy Eating Index scores, the academy reported.

Another factor in the reduction of obesity of children ages 2-4 may come from an additional change to the package, according to Cox. The package allows parents to substitute fresh fruit or vegetables for baby food, she said.

The scores measure how well foods within a diet align with recommendations from the U.S. Health Department's Dietary Guidelines for Americans. WIC households' purchases of total calories declined by 11 percent after the package change. At the same time, purchases of fresh fruits and vegetables increased.

Data also show there have been fewer juice purchases at the same time that the intake of fruits and whole grains has risen, the academy said.

Although the analysis revealed overall declines in obesity following changes to the package, variation between results for states suggest the effectiveness of the programs implemented by states wasn't even, the academy stated.

Missouri shrank the percentage of small children in the WIC program who were considered obese from 14.6 percent in 2008 to 13 percent in 2014. National percentages declined from 15.1 percent in 2008 to 14.2 percent in 2014.

There was little enough difference, year to year, in 15 states that the CDC determined the obesity rates among them remained unchanged. Four states — Nebraska, Ohio, West Virginia and North Carolina — showed increases in obesity rates for the small children. Nebraska, for example, showed a sharp increase — 14.4 percent of 2- to 4-year-olds in the WIC programs were listed as obese in 2010. The percentage rose to 17.2 percent in 2012.

Further improvements are attainable, Cox said.

"Missouri is reviewing U.S. Department of Agriculture-allowable dietary offerings to increase the availability and consumption of nutritious food options that are appealing to participants, such as string cheese and yogurt in smaller container sizes," Cox said.

Although the academy report said further research is needed to determine why there were differences in outcomes, it determined that — at least for very young children — changes to the program reversed an upward obesity trend.

"The 2009 WIC food package change may have helped to reverse the rapid increase in obesity prevalence among WIC participants observed before the food package change," the academy concluded.

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