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Introduction
Persistent disparities in overweight among children with lower economic resources compared to those with higher economic resources represent a critical challenge for public health in the USA. 1-3 Therefore, it is important to understand the impact of significant decreases in economic resources at the broader community level (eg, business closings, changing economic security) on childhood overweight/obesity outcomes. The recent economic recession represents an opportunity to test whether changing economic conditions have consequences on childhood overweight/obesity risk.
Research on the effects of recessions on weight status is mixed, with some studies in the USA suggesting that recessions are associated with increased overweight/obesity 4-6 (or correspondingly, that improving economic conditions are associated with decreased overweight/obesity), 7 while others suggest that recessions are associated with decreased overweight/obesity. 8 9 Most of these studies rely on repeated cross-sectional data, self-reported anthropometric measurements or a single measure of economic hardship (eg, unemployment). Most prior research uses individual-level employment status, which can be correlated with unobserved traits that also influence health, thus producing misleading associations, and fails to capture changes in spending that occur among families who perceive greater economic uncertainty, but do not actually become unemployed, and among those who have experienced economic hardships, owing to potential losses in investments or a reduction in work hours. 10 11 Prior literature is also limited to adults, and few studies have leveraged longitudinal data to compare the same individual to himself or herself over time.
We improve on previous studies by using measured longitudinal anthropometric measurements to examine the impact of macroeconomic indicators on children's overweight/obesity risk. We investigate the association between two indicators of economic conditions (county-level unemployment and foreclosure) and overweight/obesity among children in California between 2008 and 2012. The overlap between this study period and the Recession (December 2007 to June 2009), 12 as well as our ability to overcome major sources of confounding by comparing children to themselves over time, provides a unique opportunity to better identify changes in children's weight as a result of changing economic conditions.
Economic theory suggests that changing macroeconomic conditions, such as those experienced during a recession, could impact health through several pathways, including reductions in income and changes in time allocation. 13 Lakdawalla and Philipson 14 propose an upside down u-shaped...