| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas.
Address reprint requests to: Carmen Radecki Breitkopf, PhD, 301 University Boulevard, Galveston, TX 77555–0587; e-mail: cmradeck{at}utmb.edu.
 |
ABSTRACT |
|---|
TOP
 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
METHODS: A total of 1,709 Caucasian, African-American, and Latina women aged 12–58 years attending a federally funded family planning clinic reported their weight loss behaviors during the past 30 days, including using diet pills, exercising, purging (vomiting, laxatives, diuretics), and dieting. Approximately 60% (n = 999) had a body mass index of 25 or greater.
RESULTS: Overall, 35.3% (n = 603) of women dieted, 43.7% (n = 746) exercised, 15.1% (n = 258) used diet pills, and 4.3% (n = 69) purged. Only 14.8% (n = 253) of the sample reported both dieting and exercising. The odds of exercising for weight loss decreased as parity increased. Those who smoked currently or in the past were more likely than nonsmokers to report purging (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.2, 5.4). African Americans were least likely to diet or exercise compared with Caucasians and Latinas. Exposure to family members using diet pills (OR 4.6; 95% CI 3.2, 6.5), dieting (OR 2.1; 95% CI 1.6, 2.8), or purging (OR 5.6; 95% CI 2.7, 11.9) was associated with increased odds of performing these behaviors oneself.
CONCLUSION: This research demonstrates that low-income women frequently use maladaptive strategies, such as diet pills and purging, to lose weight. Obesity and family exposure to these behaviors places women at increased risk of unhealthy behaviors. Interventions designed to reduce obesity must include precautions regarding the dangers of these practices.
LEVEL OF EVIDENCE: III
In the United States, a steep, inverse gradient exists between socioeconomic status (SES) and obesity rates among white, black, and Hispanic women.5–9 In fact, women of lower SES are 50% more likely to be obese than women of higher SES.4 Compared with women with higher incomes, women with lower incomes are less attentive to their weight (ie, have a higher threshold for noticing weight gain and for taking action to lose weight), perceive less social support from friends to engage in healthy diet and exercise behavior, and engage in fewer healthy (but not unhealthy) dieting practices.10 These data, however, reflect patterns observed among primarily Caucasian women. Few studies have focused on behaviors to reduce body weight among minority women of lower SES. One study that examined obesity and weight control practices among low SES African-American women demonstrated that of the women attempting to lose weight, caloric restriction was used by 80% of women whereas only 50% were also using physical activity. This study did not assess other weight loss practices.11 In addition, previous research has included different time frames for retrospective reporting of behaviors12 and extended time periods (eg, past 2 years) for retrospective accounts,13 which may introduce recall bias. Finally, the reliance on self-reported weight and height for calculations of body mass index (BMI) is necessary for large national surveys; however, weight may be misrepresented when self-report is used to collect these data, particularly among overweight women.14
This investigation fills an important gap in the literature by examining the prevalence of 4 weight reduction behaviors among low-income African-American, Latina, and Caucasian women attending federally funded clinics for routine health care. Specifically, we examined dieting (eating less or differently to lose weight or keep from gaining weight), exercising for the purpose of weight loss (to burn calories or fat), purging (including vomiting, use of laxatives or diuretics), and ingestion of nonprescription diet pills. These behaviors were selected because they are associated with both long- and short-term health consequences and are modifiable using appropriate interventions.15 Additionally, we examined sociodemographic (eg, education, parity, employment, age) and behavioral correlates (eg, smoking, daily physical activity not motivated by weight loss) of weight reduction behaviors in a multivariable fashion. Finally, we investigated the potential role of social influence on dieting, vomiting, and using diet pills by inquiring about our subjects’ awareness of family or friends who perform these behaviors.
|
MATERIALS AND METHODS |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
A total of 2,333 women were offered a survey in the 2 study clinics. Approximately 19% (n = 445) refused to participate. Women who refused were, on average, older (28 years versus 25 years, P < .001) and more likely to be Latina (50.5% Latina versus 20.5% Caucasian and 29.1% African American, P < .001) as compared with women who agreed to participate. Thus, 1,888 surveys were received during the study period. A total of 91 women who returned a survey were of multiple or unspecified backgrounds (Asian/Pacific Islander, multi-ethnic, Native American, other); these women were excluded from analysis because of their small numbers and an inability to conduct meaningful comparisons. Of the remaining 1,797 surveys, 88 (4.9%) contained critical missing data and could not be analyzed. A total of 1,709 surveys (90.5% of all surveys returned) were analyzed.
Participants were asked: "During the past 30 days, did you do any of the following things to lose weight or keep from gaining weight?" The following activities were assessed using a yes/no format: diet (eat less or differently), exercise (to burn calories or fat), make yourself vomit (throw up), take diet pills (Dexatrim [Chattem, Inc; phenylpropanolamine], Metabolife [Metabolife International Inc, San Diego, CA], powders, or liquids), take laxatives (like Ex-Lax; Novartis International AG, Basel, Switzerland) or diuretics (water pills). General patterns of physical activity were assessed by the question: "In the last 3 months, how many times did you exercise or play sports for at least 20 minutes in a row?" Responses included "I did not exercise," "less than 1 time a week," "1 time a week," "2 times a week," "3 times a week," or "more than 3 times a week."
Height and weight values were those obtained from anthropomorphic data recorded in the medical chart on the day the patient completed the survey. Patients were weighed upon arrival to the clinic using a standard digital scale to the nearest 0.01 lb. Categorization of BMI (weight in kilograms divided by the square of the height in meters) was accomplished using cutoff values proposed by the World Health Organization16 (normal 18.5–24.9; grade 1 overweight 25.0–29.9; grade 2 overweight or obese 30.0–39.9; and grade 3 overweight or morbidly obese 40 or greater). Published data have supported the predictive relationship between this classification system and overall mortality among a large, prospective cohort of men and women in the United States.17
Exposure via family or friends to the use of diet pills, restricted eating, and vomiting to lose weight was assessed with items that asked women whether they had seen or heard about a family member performing the behavior. An analogous set of questions appeared for friends. Responses were made using a tabular format in which a check mark was indicative of a "yes" response.
Continuous variables are expressed as mean (M) ± standard deviation (SD). Group comparisons for continuous variables were conducted using analysis of variance or independent group t tests. Associations among categorical variables were analyzed using the Fisher exact or 
2 statistics and Spearman correlation. Logistic regression analyses were used to evaluate relationships among weight reduction behaviors, race/ethnicity, sociodemographic and behavioral correlates, and social influence, with models examining each of the 4 behaviors independently. Body mass index was included in all analyses; daily physical activity (not for weight loss purposes) was excluded from the exercise model. Nagelkerke18 R2 and Hosmer and Lemeshow19 statistics provided estimates of overall model fit. Odds ratios (ORs) and Bonferroni adjusted 95% confidence intervals (CIs) were estimated. A 2-sided significance level of .05 was used to indicate statistical significance.
|
RESULTS |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
). Nearly half (47.9%, n = 819) were unemployed, 20% (n = 339) reported no household income from any source, and 69.6% (n = 1189) received their medical care under Title XX (low-income) funding. The majority of women were born in the United States, whereas 15.2% (n = 259) were born in Mexico. The majority of our sample reported that their primary residence was rented (versus owned) and located in a township with a population less than 50,000.
|
Overall, 43.7% (n = 746) of women exercised for the purpose of weight loss, 35.3% (n = 603) dieted, 15.1% (n = 258) reported using diet pills, and 4.3% (n = 69) reported purging during the past 30 days. As expected, analyses stratified by BMI demonstrated that women who reported performing the weight loss behaviors during the past month were more likely to be overweight, obese, or morbidly obese (BMI 
25) compared with women who were underweight or normal weight (BMI 
24.9), all P < .001. Specifically, of those who reported exercising for weight loss, 67% had a BMI of 25 or greater, and of those who reported dieting, 73% were in the higher BMI strata. Approximately 80% of women who indicated that they used diet pills or purged during the last month were overweight, obese, or morbidly obese. Missing data ranged from approximately 2.0% for exercising (n = 35) and dieting (n = 36) to 3.5% and 5.1% for diet pill use (n = 59) and purging (n = 88), respectively.
Table 2 presents Spearman correlation coefficients between the weight reduction behaviors. Overall, 57% (n = 972) of women reported that they performed at least 1 of the 4 behaviors during the past 30 days. Approximately 27% (n = 470) reported 1 behavior, 19% (n = 328) reported 2 behaviors, 9% (n = 146) reported 3 behaviors, and 2% (n = 28) of the sample reported having performed all 4 behaviors. A higher proportion of African-American women (54%), relative to Latina (40%) and Caucasian (38%), reported not performing any of the behaviors (P < .001). The prevalence of the behaviors individually and in combination is presented in Table 3. Nearly 12% (n = 16) of morbidly obese women performed 3 of the 4 behaviors (necessarily including either purging or the use of pills) during the previous month, and an additional 3% (n = 4) reported performing all 4 behaviors in the last 30 days.
|
|
More than half of the women reported seeing or hearing about friends (56.6%, n = 967) or family (55.5%, n = 948) dieting to lose weight. A total of 42.0% (n = 717) of women reported seeing or hearing about a friend using diet pills, and 34.5% (n = 590) reported awareness of a family member using diet pills. About half as many women reported awareness of a family member vomiting to lose weight (5.1%, n = 88) as friends vomiting to lose weight (11.5%, n = 197). Caucasian women demonstrated the highest proportion of exposure to family members dieting (62.2%) compared with Latinas or African-American women (59.6% and 51.1%, respectively; P < .001). Similarly, 67.6% of Caucasian women reported awareness of friends dieting compared with 54% of Latinas and 55.2% of African-American women (P < .001).
In bivariate analyses, exercising for weight loss was associated with fewer children (P < .001), higher education levels (P < .01), and not smoking (P < .05). Dieting was associated with being employed (P < .05), having a higher education (P < .01), seeing or hearing about dieting among family or friends (both P < .001), engaging in regular physical activity (P < .001), and older age (P = .01). Use of diet pills was associated with being employed (P < .01), attending college (P < .05), smoking (P < .01), exposure to diet pill use among family or friends (both P < .001), and engaging in regular physical activity (P < .001). Purging was associated with regular physical activity (P < .05). Specifically, purging was noted among 2.8% of women reporting no physical activity, 6.1% among those engaging in physical activity 1 time per week, 6.2% among those who were active 2 to 3 times per week, and 3.8% among women reporting regular physical activity 4 or more times per week. Additionally, women who reported awareness of a family member who vomited to lose weight had a prevalence of purging that was more than 6 times that of women who reported no exposure to purging among family (19% versus 3%, P < .001). Similarly, the prevalence of purging was 8% among women who were exposed to friends who purged compared with 3% among women who did not know friends who purged (P < .01).
Multivariable simultaneous logistic regression analyses were undertaken to evaluate associations among the weight-reduction behaviors and race/ethnicity, demographic (age, parity, employment, education, marital status) and behavioral (smoking, regular physical activity) factors, BMI, and social influence (Tables 4 and 5). Nonsignificant values for the Hosmer and Lemeshow19 statistic were obtained for each of the 4 models, suggesting good model fit. Nagelkerke18 R2 values were .23 for dieting, .25 for use of diet pills, .16 for purging, and .09 for exercising for weight loss, suggesting that the models accounted for 9% to 25% of the variance. Correct classification of predicted and observed cases was 96% for purging, 85% for diet pills, 70% for dieting, and 61% for weight-reducing exercise.
|
|
). The ORs for dieting increased across BMI and were greater among older women, women who engaged in physical activity more than once per week, and women exposed to dieting within the family (Table 4).
Exercising to achieve weight loss was significantly associated with race/ethnicity, BMI, parity, and education (Table 4). Compared with Caucasian women, African-American women were half as likely to engage in exercise for weight loss. Women with children were about half as likely to report weight-reducing exercise as women with no children.
Diet pill use was associated with race/ethnicity, BMI classification, engaging in physical activity, and awareness of family members who used diet pills (Table 5). Caucasian women and Latinas were, respectively, 1.6 (95% CI 1.0, 2.5) and 1.8 (95% CI 1.2, 2.8) times more likely than African-American women to ingest diet pills. Overweight women were more than twice as likely to use diet pills (OR 2.4; 95% CI 1.5, 3.7), and obese women were more than 4 times as likely to use pills relative to normal weight women (OR 4.3; 95% CI 2.8, 6.7). The morbidly obese were more likely than women of normal weight to report using diet pills during the past month (OR 3.2; 95% CI 1.7, 5.9). Women who engaged in physical activity from 2 to 3 times per week, were 1.7 (95% CI 1.1, 2.4) times more likely than women who did not engage in physical activity to report using diet pills. The odds of diet pill use were no greater among those engaging in physical activity more regularly (4 or more times per week) than women who were not physically active. Women who reported seeing or hearing about a family member using diet pills were nearly 5 times more likely to report having taken diet pills themselves during the past month (OR 4.6; 95% CI 3.2, 6.5).
Based upon chart review, 88% of women who indicated on the survey that they took diet pills during the past 30 days failed to inform their health care provider during their visit. Thus, although approximately 15% of the sample reported diet pill use on the survey, the prevalence of diet pill use based on chart review was only 2%. Women who informed their health care provider did not significantly differ from women who did not inform their provider on age (P = .24), education (P = .36), or race/ethnicity (P = .48).
Vomiting or use of laxatives or diuretics was significantly associated with race/ethnicity, being overweight or obese, ever smoking, engaging in moderate physical activity, and knowing of a family member who vomited to lose weight (Table 5). Overweight (OR 3.0; 95% CI 1.3, 6.8) and obese (OR 3.2; 95% CI 1.4, 7.5) women were more likely to purge relative to women within the normal BMI range. Compared with nonsmokers, previous smokers and current smokers were about 2.5 times more likely to purge (95% CI 1.2, 5.4). Regular physical activity 2 to 3 times per week was associated with about a 2-fold increase in purging over women who reported no physical activity (OR 2.3; 95% CI 1.2, 4.6). Women who reported seeing or hearing about a family member vomit to lose weight were nearly 6 times more likely to have purged within the past 30 days than women with no family exposure to purging (OR 5.6; 95% CI 2.7, 11.9).
|
DISCUSSION |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
Despite federal recommendations to reduce obesity through diet modification and increased exercise,23 only 15% of the women we studied engaged in both of these behaviors, which is less than the national estimate of 17.5%.24 This is concerning given the high rate of obesity in our population. African Americans in particular had high rates of obesity and the highest rate of morbid obesity, yet more than half had not attempted to lose weight in the last month. Furthermore, African Americans dieted and exercised less frequently than Caucasians or Latinas, a finding that is consistent with other research.25 It may not be assumed, however, that this reflects an acceptance of obesity among African-American women, as 5% reported purging and 12% reported using diet pills in the last month. These findings are consistent with those of Biener et al,26 who demonstrated that even among normal-weight women, those who engaged in risky weight loss practices, such as fasting, vomiting, and taking diet pills, were twice as likely to be black. Given the higher rates of obesity found among African-American women1,2,27 and the knowledge that maladaptive strategies to lose weight are not uncommon, efforts to educate this population about safe and effective weight loss are essential.
Exercise has been demonstrated to be an effective means of weight loss and maintenance, particularly among the very overweight.28 We attempted to measure exercise performed to lose weight (exercise to burn calories or fat) while also capturing more general physical activity patterns (activities and sports during the past 3 months) but acknowledge that the motivation underlying both types of regimens could be weight loss. We identified parity as a potential impediment to exercising among low-income women; the odds of exercising decreased by 40% among women with 1 child and by 50% among women with 2 or more children. This finding suggests that promoting exercise for weight loss among low-income women should address ways to include their children in exercise regimens; low-income women are less likely to have access to a fitness center that provides childcare services or an opportunity to exercise during the workday at an onsite or corporate facility. Future investigations should attempt to make finer distinctions between the amount and type of exercise performed and to identify the specific weight loss goals underlying the exercise regimen.
We observed strong family influences on maladaptive weight loss behaviors. Women who knew of a family member using diet pills or purging to lose weight were 5 and 6 times more likely, respectively, to report using these methods themselves. This suggests that these mal-adaptive behaviors are learned in the home and shared among family members. Thus, clinicians may be able to obtain information about these activities in other family members as a way of introducing this topic if direct inquiry is too threatening or likely to result in socially desirable responses.
Overall, 15% of our sample reported using diet pills during the last month, which is within the 7–28% range observed in other investigations of primarily Caucasian women.13,29 It may be argued that several of the pill formulas that women used during the study interval may become inaccessible because of controversies surrounding their safety. Nevertheless, our findings suggest that as new formulations become available, these products will be used among overweight and obese women, usually in combination with other methods to lose weight. Simultaneous use of several weight loss methods suggests that women may use diet pills to achieve weight loss that is not accomplished through other methods, such as exercise. For instance, those engaging in regular physical activity up to 3 times per week were 1.7 times more likely to report using diet pills than nonexercisers. Those who reported physical activity 4 or more times per week showed no association with diet pill use, although they may represent a subgroup of health-conscious individuals who reject the idea of using chemical substances to control weight. The frequency of combining diet pill use with other methods to reduce weight suggests that discussion of weight loss expectations, in addition to short and long-term goals, may be an important component to patient education regarding obesity.
Relative to normal-weight individuals, morbidly obese women were more likely to use multiple methods in their attempt to lose weight. In fact, 12% of women in this group reported performing 3 of the 4 behaviors during the past month. On average, morbidly obese women were 4 times more likely to report dieting, 3 times more likely to use diet pills, and twice as likely to report exercising or purging. These data demonstrate that low-income, obese women will resort to multiple, as well as unsafe, methods to achieve weight loss and dispel the myth that these activities are more common among thin women.
Diet pill use and purging methods, including use of laxatives and diuretics, are associated with significant health risks, especially when used on a long-term basis. Our study found that 4.3% of all women surveyed purged during the last 30 days. This finding is consistent with Jeffery and French10 who found that 4% of primarily Caucasian women in a lower income category (annual income $19,000 or less) reported purging within the past year. Although we did not find evidence of a relationship between age and purging or diet pill use, national studies of weight-control practices suggest that vomiting and pill use may be prominent among females during the adolescent years.30 Clinicians should be aware of the temptation to use these maladaptive strategies to lose weight and counsel women appropriately.
We observed that women frequently did not discuss diet pill use with their health care providers and that the prevalence of diet pill use was greater when estimated from the self-report survey than when estimated from the medical chart review. Although we cannot be certain that providers asked each woman about her use of over-the-counter medications, our findings imply a lack of disclosure that is similar to previous reports on use of dietary supplements and nonprescription medications.31–34 Hesitancy to report diet pill use, concurrent use of laxatives/diuretics and cigarettes, and recent safety concerns surrounding nonprescription diet pill formulations may place overweight low-income women at increased risk for adverse health outcomes. Thus, clinicians need to routinely inquire about these behaviors at screening visits.
The findings of our research must be tempered by the limitations inherent to our data. Behavioral performance was determined by retrospective self-report, which is vulnerable to recall bias and biases associated with socially desirable response tendencies. In our study, however, we limited recall to behaviors performed during the past 30 days and included 4 behaviors that likely differ in their degree of social desirability to reduce the potential impact of these biases. Because of our geographic location, women who self-identified as Latina were primarily Mexican American; therefore, our findings may not apply to Latinas of non-Mexican backgrounds. Finally, we used nonrandom sampling to recruit study participants from 2 women’s health clinics in the same geographical region; therefore, the generalizability of our findings should be limited accordingly.
This research demonstrates that the performance of unhealthy behaviors to achieve weight loss is relatively common among low-income and minority women. In addition, this study identified important correlates of dieting, exercising, purging, and using diet pills, such as parity, exposure to the behaviors through family members, and cigarette smoking. These findings can be applied in practice settings in ways that emphasize safe, practical, and effective options for weight loss among low-income, overweight, and minority women to invoke positive behavior change and reduce the burden of obesity.
|
Footnotes |
|---|
Received August 15, 2003. Received in revised form November 5, 2003. Accepted November 13, 2003.
|
REFERENCES |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
2. Ni H, Schiller J, Hao C, Cohen RA, Barnes P. Early release of selected estimates based on data from the 2002 National Health Interview Survey. National Center for Health Statistics. Available at: http://www.cdc.gov/nchs/nhis.htm. Retrieved August 8, 2003.
3. Allison DB, Fontaine KR, Manson JE, Stevens J, VanItallie TB. Annual deaths attributable to obesity in the United States. JAMA 1999;282:1530–8.
4. US Department of Health and Human Services. The Surgeon General’s call to action to prevent and decrease overweight and obesity. Rockville (MD): US Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001.
5. Burke GL, Savage PJ, Manolio TA, Sprafka JM, Wagenknecht LE, Sidney S, et al. Correlates of obesity in young Black and White women: the CARDIA Study. Am J Pub Health 1992;82:1621–5.
6. Sobal J, Stunkard AJ. Socioeconomic status and obesity: a review of the literature [review]. Psychol Bull 1989;105: 260–75.[Medline]
7. Stern MP, Pugh JA, Gaskill SP, Hazuda HP. Knowledge, attitudes, and behavior related to obesity and dieting in Mexican Americans and Anglos: the San Antonio Heart Study. Am J Epidemiol 1982;15:917–28.
8. Winkleby MA, Fortmann SP, Barrett DC. Social class disparities in risk factors for disease: eight-year prevalence patterns by level of education. Prev Med 1990;19:1–12.[Medline]
9. Pamuk E, Makuc D, Heck K, Reuben C, Lochner K. Socioeconomic Status and Health Chartbook. Health, United States, 1998. Hyattsville (MD): U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 1998.
10. Jeffery RW, French SA. Socioeconomic status and weight control practices among 20- to 45-year-old women. Am J Public Health 1996;86:1005–10.
11. Jacobson TA, Morton F, Jacobson KL, Sharma S, Garcia DC. An assessment of obesity among African-American women in an inner city primary care clinic. J Natl Med Assoc 2002;94:1049–57.[Medline]
12. Story M, French SA, Resnick MD, Blum RW. Ethnic/racial and socioeconomic differences in dieting behaviors and body image perceptions in adolescents. Int J Eat Disord 1995;18:173–9.[Medline]
13. Blanck HM, Khan LK, Serdula MK. Use of nonprescription weight loss products: results from a multistage survey. JAMA 2001;286:930–5.
14. Rowland ML. Self-reported weight and height. Am J Clin Nutr 1990;52:1125–33.
15. French SA, Jeffery RW. Consequences of dieting to lose weight: effects on physical and mental health [review]. Health Psychol 1994;13:195–212.[Medline]
16. World Health Organization (WHO). Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser 1995;854:1–452.[Medline]
17. Calle EE, Thun MJ, Petrelli JM, Rodriguez C, Heath CW Jr. Body-mass index and mortality in a prospective cohort of US adults. N Engl J Med 1999;341:1097–105.
18. Nagelkerke NJ. A note on general definition of the coefficient of determination. Biometrika 1991;78:691–2.
19. Hosmer DW, Lemeshow S. Applied logistic regression. New York (NY): John Wiley and Sons; 1989.
20. Horm J, Anderson K. Who in America is trying to lose weight? Ann Intern Med 1993;119 suppl 7, pt 2:672–6.
21. Serdula MK, Williamson DF, Anda RF, Levy A, Heaton A, Byers T. Weight control practices in adults: Results of a multistate telephone survey. Am J Public Health 1994;84: 1821–4.
22. Schreiber GB, Robins M, Striegel-Moore R, Obarzanek E, Morrison JA, Wright DJ. Weight modification efforts reported by black and white preadolescent girls: National Heart, Lung, and Blood Institute Growth and Health Study. Pediatrics 1996;98:63–70.
23. Nestle M, Jacobson MF. Halting the obesity epidemic: A public health policy approach. Public Health Rep 2000; 115:12–24.[Medline]
24. Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States. JAMA 2001;286:1195–1200.
25. Wing RR, Kuller LH, Bunker C, Matthews K, Caggiula A, Meihlan E, et al. Obesity, obesity-related behaviors and coronary heart disease risk factors in black and white premenopausal women. Int J Obes 1989;13:511–9.[Medline]
26. Biener L, Heaton A. Women dieters of normal weight: their motives, goals, and risks. Am J Public Health 1995; 85:714–7.
27. Freedman DS, Khan LK, Serdula MK, Galuska DA, Dietz WH. Trends and correlates of class 3 obesity in the United States from 1990 through 2000. JAMA 2002;288: 1758–61.
28. Schmitz KH, Jacobs DRJr, Leon AS, Schreiner PJ, Sternfeld B. Physical activity and body weight: associations over ten years in the CARDIA study. Coronary Artery Risk Development in Young Adults. Int J Obes 2000;24: 1475–87.
29. Levy AS, Heaton AW. Weight control practices of US adults trying to lose weight. Ann Intern Med 1993;119 suppl 7, pt 2:661–6.
30. Serdula MK, Collins ME, Williamson DF, Anda RF, Pamuk E, Byers TE. Weight control practices of U.S. adolescents and adults. Ann Intern Med 1993;119 suppl 7, pt 2:667–71.
31. Dieter RS, Vorperian VR. Sudden cardiac death in a patient taking an over-the-counter diet pill. WMJ 2000;99: 20–2.
32. Hensrud DD, Engle DD, Scheitel SM. Underreporting the use of dietary supplements and nonprescription medications among patients undergoing a periodic health examination. Mayo Clin Proc 1999;74:443–7.[Medline]
33. Herbert V. Underreporting of dietary supplements to health-care providers does great harm. Mayo Clin Proceed 1999;74:531–2.
34. Naylor S, Gleich GJ. Silent but widespread use of dietary supplements. Mayo Clin Proceed 1999;74:845–6.
This article has been cited by other articles:
|
|
 |
|
  C. Keller, J. Fleury, and A. Rivera Visual Methods in the Assessment of Diet Intake in Mexican American Women West J Nurs Res, October 1, 2007; 29(6): 758 - 773. [Abstract] [PDF]
|
|
|
|
 |
|
 Unhealthy Weight-Loss Strategies Among Low-Income Women Journal Watch Women's Health, March 23, 2004; 2004(323): 10 - 10. [Full Text]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
