PEDIATRICS Vol. 111 No. 1 January 2003, pp. 67-74
Overeating Among Adolescents: Prevalence and Associations With Weight-Related Characteristics and Psychological Health
* Private Practice, Minneapolis, Minnesota
Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Objective. To assess the prevalence of overeating among adolescents and to examine associations between overeating and sociodemographic characteristics, weight status, dieting behaviors, body satisfaction, depressive mood, self-esteem, and suicide.
Method. A school-based sample of 4746 boys and girls in public middle and high schools in Minnesota completed the Project EAT (Eating Among Teens) survey and anthropometric measurements of height and weight.
Results. Overall, 17.3% of girls and 7.8% of boys reported objective overeating in the past year. Youths who engaged in overeating were more likely to be overweight or obese, to have dieted in the past year, to be trying to lose weight currently, and to report that weight and shape are very important to their overall feelings about self. Youths who met criteria for binge eating syndrome (high frequency of objective overeating with loss of control and distress regarding the binge eating) scored significantly lower on measures of body satisfaction and self-esteem and higher on a measure of depressive mood than those who reported either subclinical or no binge eating. Overeating was associated with suicide risk; more than one fourth of girls (28.6%) and boys (27.8%) who met criteria for binge eating syndrome reported that they had attempted suicide.
Conclusions. Overeating among adolescents is associated with a number of adverse behaviors and negative psychological experiences. As the current study is cross-sectional, it is not possible to ascertain cause and effect. Future research should seek to identify whether objective overeating is an early warning sign of additional psychological distress or is a potential consequence of compromised psychological health. Clinical implications are discussed.
Key Words: adolescents • overeating • binge eating • body satisfaction • self-esteem • depression • suicide
Abbreviations: BED, binge eating disorder • DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition • SES, socioeconomic status • BMI, body mass index • QEWP-R, Questionnaire on Eating and Weight Patterns-Revised
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Overeating is a behavior that begins for many during adolescence,1,2 a time at which weight concerns also arise.3 Studies have found that objective overeating is prevalent among adolescents and has been linked with problematic weight-related behaviors and psychological challenges. The population-based prevalence of binge eating (objective overeating with a sense of loss of control over what or how much one is eating) among youths is as high as nearly 30% for boys and 46% for girls.4,5 However, few studies have attempted to assess the prevalence of differing levels of overeating among adolescents and to identify differences in psychological health by severity of overeating.
Overeating is a critical area to study because of the problematic behaviors and psychological problems associated with this eating disturbance. Some of the challenges associated with overeating include behaviors such as disordered eating6,7 and dietary restraint.4,8,9 In turn, disordered eating and dietary restraint may cause some individuals to binge eat, and binge eating has been linked with obesity. In the past 30 years, the prevalence of adolescent obesity has increased by >75%.10 Binge eating has also been found to be associated with adverse psychological health such as body image dissatisfaction and distortion,4,7,9,11 low self-esteem,4,8,11 depression,4,6,7 and general psychiatric distress.4,12,13
Several problems exist in the current literature related to overeating among youths. First, it is not clear among youths whether objective overeating by itself is associated with these behavioral and psychological problems or an individual needs to endorse a high frequency of overeating, loss of control, and accompanying distress (such as would meet clinical criteria for binge eating disorder [BED] according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV],14 but that is referred to in the present study as binge eating syndrome) to yield these significant associations. Several studies with adults have indicated that the frequency and severity do not yield significantly different results among all individuals who binge eat. Results from these studies revealed that individuals with BED and those with "subclinical" or "subthreshold" levels of binge eating both report significant psychiatric distress compared with those who did not binge eat.9,15–17 However, many individuals report subclinical levels of overeating and binge eating before meeting full criteria for BED.18,19
A second problem relates to the definition of overeating among youths. Results from a qualitative study by Neumark-Sztainer and Story20 found that youths defined overeating in different ways. Factors important in determining whether they had overeaten or binged included how much they ate, types of foods consumed, emotional consequences after overeating (eg, feeling guilty), and reasons for overeating. A more stringent method of evaluating overeating among youths and associated problems is needed.
Measurement is a third problem. Assessment issues are most evident when inspecting the wide range of prevalence rates found among adolescent and adult populations, likely as a result of varying definitions used to measure overeating and binge behavior. Although only interview methods allow for clinical diagnosis, self-report instruments based on paper-and-pencil measures are convenient, confidential, and efficient in both time and cost. Psychometrically sound tools to assess different aspects of objective overeating, including the behavior itself, frequency, perceived loss of control, and distress after the overeating episode and measures that follow criteria outlined in the DSM-IV,14 are critical toward a greater understanding of overeating.
The current study expands on the limited body of research in this area by using a population-based sample that allows us to stratify results by gender, a method for assessing different levels of overeating, and a survey that assesses weight-related behaviors and psychological problems associated with overeating among adolescents. Our first aim was to assess the prevalence of overeating categories (none, objective overeating, subclinical binge eating, and binge eating syndrome) among adolescent boys and girls.
Our second aim was to determine the associations between overeating and dieting behaviors, weight status, body satisfaction, self-esteem, depressive mood, and suicide. Three hypotheses were central to this second aim. First, we hypothesized that youths who overeat would be more likely than youths who do not overeat to have problems with weight-related characteristics. Specifically, youths who overeat would be more likely than youths who do not overeat to weigh more, to meet criteria for obesity, to have dieted in the past year, to be currently dieting, and to place great importance on weight and shape. Second, we hypothesized that youths who overeat would report a more compromised psychological health (poorer body satisfaction, greater symptoms of depression, lower self-esteem, and more suicidal thoughts and attempts) than youths who do not overeat. Finally, we hypothesized that boys and girls who meet criteria for binge eating syndrome would have the least healthy physical and psychological outcomes of all 4 overeating categories and that youths who report no overeating would have the most healthy outcomes.
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METHODS |
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Study Population and Design
Participants in this study included a sample of 4746 students (2377 boys and 2357 girls; 12 students had missing data for gender) in public middle and high schools in the greater Minneapolis/St Paul metropolitan area of Minnesota. The study aimed to attract diversity by race and economic status; 31 schools serving socioeconomically and ethnically diverse communities agreed to participate in the study.
Students completed the Project EAT (Eating Among Teens) survey in health, physical education, or science class. The confidential survey was designed to assess eating and weight-related attitudes and behaviors among adolescents. Height and weight measurements were obtained by trained research staff in a private screened area. Standardized anthropometric procedures were used. Data were collected in compliance with the University of Minnesota’s Institutional Review Board and Human Subjects’ Committee and with the consent processes for each school district’s research board. The student response rate was 81.5%.
Racial/ethnic backgrounds of the respondents were as follows: white (51.3% boys, 45.6% girls), black or African American (17.9% boys, 20.1% girls), Asian American (17.8% boys, 20.6% girls), Hispanic (6.5% boys, 5.2% girls), or other (6.5% boys, 8.5% girls). Socioeconomic status (SES) based on parental education and employment status was as follows: low SES (14.5% boys, 20.4% girls), low-middle (18.5% boys, 19.1% girls), middle (27.6% boys, 25.6% girls), upper-middle (25.3% boys, 21.5% girls), and high (14.1% boys, 13.4% girls).
Participants ranged in age from 11 years or younger to 18 years or older; most students were between 13 and 16 years, inclusive (75.6% boys, 73.7% girls). Approximately 14.6% of boys and 20.0% of girls were categorized as "overweight" (body mass index [BMI] >85th percentile but <95th percentile for their gender and age), and 16.6% of boys and 12.6% of girls were categorized as "obese" (BMI 
95th percentile for their gender and age) according to the Centers for Disease Control and Prevention by direct measures of height and weight.21
Measures
The Project EAT survey is composed of 221 questions that measure nutritional and weight-related factors. The survey was developed with guidance from multidisciplinary professional teams, focus groups with youths, and pilot screenings. All items, except the anthropometric height and weight measurements, were based on self-report.
Overeating
Overeating was assessed with 4 questions adapted from the adult version of the Questionnaire on Eating and Weight Patterns-Revised (QEWP-R),22 a self-report measure that differentiates between clinical and nonclinical binge eaters.23 The QEWP-R is based on diagnostic criteria for BED in the DSM-IV.14 An adolescent version of the QEWP-R exists,6 but reliability and validity estimates were not available at the time of administration.24 Thus, a revised version of the psychometrically sound adult QEWP-R was selected for use.
Four components of overeating were assessed: objective overeating, loss of control, binge frequency, and distress. Objective overeating: "In the past year, have you ever eaten so much food in a short period of time that you would be embarrassed if others saw you (binge-eating)?" (yes/no). Loss of control: "During the times when you ate this way, did you feel you couldn’t stop eating or control what or how much you were eating?" (yes/no). Frequency of binge eating: "How often, on average, did you have times when you ate this way—that is, large amounts of food plus the feeling that your eating was out of control?" (nearly every day, a few times a week, a few times a month, less than once a month). Distress: "In general, how upset were you by overeating (eating more than you think is best for you)?" (not at all, a little, some, a lot).
All students were grouped into 1 of 4 categories based on recommendations from the QEWP-R: no overeating ("no" to objective overeating), objective overeating ("yes" to objective overeating but no loss of control), subclinical binge eating ("yes" to both objective overeating and loss of control but low binge frequency or no significant distress regarding the binge eating), and binge eating syndrome ("yes" to objective overeating, loss of control, binge eating "a few times a week" or "nearly every day," and upset "some" or "a lot" by overeating). The definition of binge eating syndrome is based on the DSM-IV criteria for BED.14 However, because clinical diagnoses of BED cannot yet be made on the basis of a self-report survey, we refer to this constellation of behaviors as binge eating syndrome in the current study.
SES
The highest level of parent education was used to establish SES for most youths; however, other factors (family eligibility for public assistance, eligibility for free or reduced-cost school meals, and employment status of mother and father) were combined in an algorithm using a method of classification and regression trees for students who indicated that they did not know their parent’s educational level (n = 1058, 22.3%) or when there were missing data. The classification and regression trees method was found to be predictive of parent education among participants who completed all questions; using this cartography allowed for the reduction of the number of missing SES values to 4.1% (n = 196).
Measured Height and Weight and BMI
Height and weight measurements were obtained in a private screened area using standardized equipment and procedures. BMI was calculated using the standard metric formula (weight [kg]/height [m]2). Obesity status was identified using reference data from the Centers for Disease Control and Prevention21 and based on gender and age,25 with the following guidelines: underweight (BMI <15th percentile), average weight (BMI 15th percentile but <85th percentile), overweight (BMI 85th percentile but <95th percentile), and obese (BMI 95th percentile).26
Dieting
Dieting in the past year and current intentions to modify weight were assessed. "During the past year, have you done anything to try to lose weight or keep from gaining weight?" (yes/no) and "Are you currently trying to... (lose weight, stay the same weight, gain weight, or not doing anything about their weight)?"
Body Satisfaction
Body satisfaction, assessed with a modified version of Pingitore’s scale,27 included evaluations of body parts and an overall average composite score. Higher scores indicate greater body satisfaction. Reliability estimates for the current sample were high; Cronbach’s 
for boys was 0.93 and for girls was 0.92 for the composite scale scores.
Weight/Shape Importance
Weight and shape importance was assessed. "During the past 6 months, how important has your weight or shape been in how you feel about yourself?" (not very important, played a part in how I felt about myself, among the main things that affected how I felt about myself, the most important thing that affected how I felt about myself).
Self-Esteem
A self-esteem score was created by asking youths to indicate their level of agreement with 6 sentences adapted from the Rosenberg Self-Esteem Scale.28 Scores for the composite scale ranged from 6 to 24, with higher scores indicating higher self-esteem. Reliability estimates (using Cronbach’s ) were 0.78 for both boys and girls.
Depressive Mood
A scale by Kandel and Davies29 evaluated depressive mood by asking youths to respond "not at all," "somewhat," or "very much" to the following symptoms: fatigue, sleep disturbance, dysthymic mood, hopelessness, feeling tense/nervous, worry. The summed scale had a range from 6 to 18, with higher values indicating more severe depressive mood. Cronbach’s reliability estimates for the current sample were 0.76 for boys and 0.75 for girls.
Suicide
Suicide categories were created on the basis of 2 questions that addressed suicidal ideation and attempts. "Have you ever thought about killing yourself?" and, "Have you ever tried to kill yourself?" Three categories emerged: no suicidal thoughts or attempts, yes to suicidal thoughts but no attempts, and yes to suicidal attempts. Reliability (Cronbach’s ) for the combined categories was estimated to be 0.56 for boys and 0.67 for girls.
Statistical Analyses
All analyses were run separately by gender to identify the presence and strength of associations that may be specific to either boys or girls, and were conducted using the SPSS, version 6.1 for the Macintosh.30 To describe the sample by sociodemographic variables and to estimate the prevalence of overeating, we used frequencies and percentages. Dieting behaviors, obesity status, and the importance of weight and shape were evaluated by frequencies with the 
2 statistic as a measure of significance. Mean scores on continuous measures of BMI, body satisfaction, depressive mood, and self-esteem were evaluated across overeating categories using analyses of variance. Tukey’s multiple-comparison tests were conducted to assess differences between pairs of groups at P 
.05; significance values are reported. The prevalence of suicidal thoughts and attempts across overeating category was assessed using frequencies with the 2 statistic evaluating significance across categories of overeating.
Post hoc analyses controlling for differences in BMI among overeating categories were also conducted. For continuous outcome measures (body satisfaction, depressive mood, and self-esteem), analyses of covariance were conducted with BMI as the covariate. For categorical outcome measures (dieting, importance of weight and shape, suicide), logistic regression was used. In regression analyses, overeating category was forced to enter in the first step with "no overeating" serving as the referent group; BMI entered in the second step.
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RESULTS |
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Prevalence of Overeating
Overall, 17.3% of girls and 7.8% of boys reported engaging in overeating (acknowledgment of objective overeating, regardless of loss of control, frequency, or distress). This sum represents 6.3% of girls and 4.5% of boys endorsing items for objective overeating, 7.9% of girls and 2.4% of boys with a subclinical level of binge eating, and 3.1% of girls and 0.9% of boys meeting criteria for binge eating syndrome. The prevalence rates of overeating categories across race, SES, and age are reported in Table 1 for girls and Table 2 for boys. Among girls, African Americans were least likely and Hispanics were most likely to report overeating, whereas among boys, whites were least likely and Asian Americans were most likely to report overeating. Boys who engage in objective overeating were most likely to come from low or low-middle SES; results for girls were not significant. There were no significant differences among overeating categories by age.
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Associations Among Overeating, Obesity, and Weight Characteristics
Overeating was associated with higher weight and BMI values. For girls, the average BMI for those who do not overeat was 23.0 (standard deviation [SD]: 4.9), 24.4 (SD: 5.5) for objective overeaters, 24.3 (SD: 4.9) for subclinical binge eaters, and 24.1 (SD: 4.8) for those who met criteria for binge eating syndrome (F [3, 2017] = 5.81; P < .001). The average BMI values for boys were 23.0 (SD: 4.7) for those who do not overeat, 23.4 (SD: 5.2) for objective overeaters, 25.8 (SD: 6.1) for subclinical binge eaters, and 27.4 (SD: 7.9) for those with binge eating syndrome (F [3, 2067] = 9.55; P < .0001).
Overeating was associated with obesity among boys. Boys who overeat were more likely than those who do not to meet the BMI percentile cutoff criteria for obesity (Table 3). Results for girls were not significant; however, there was a trend that girls who overeat were more likely than those who do not to be obese. Also shown in Table 3, both boys and girls who overeat were more likely to have reported dieting in the past year, trying to lose weight currently, and believing that weight and shape are the most important things that affect feelings about self. Youths who met criteria for subclinical binge eating or binge eating syndrome reported the highest rates of dieting in the past year, trying to lose weight currently, and the importance of weight and shape on their feelings about self.
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Associations Among Overeating and Body Satisfaction, Depressive Mood, and Self-Esteem
Overeating was significantly associated with body dissatisfaction (Table 4). Girls and boys who reported no overeating reported the highest satisfaction for weight and body shape and scored highest on the composite body satisfaction score when compared with their peers who reported any level of overeating.
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Overeating was associated with depressive mood. As shown in Table 4, girls and boys who reported no overeating endorsed a lower frequency and severity of depressive mood compared with their peers with objective overeating, subclinical binge eating, or binge eating syndrome. Those who met criteria for binge eating syndrome scored highest on the measure of depressive mood, and those with no overeating scored lowest.
Similar results were found for self-esteem. Youths who reported no overeating scored highest on the self-esteem scale; youths who endorsed items for binge eating syndrome criteria scored lowest (Table 4).
Associations Between Overeating and Suicide
Youths who overeat are at greater risk for suicidal thoughts and behaviors than youths who do not overeat (Table 5). More than one fourth of girls (28.6%) and boys (27.8%) who met criteria for binge eating syndrome also reported that they had attempted suicide, compared with <10% of those who do not overeat (9.8% girls, 4.9% boys).
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Post Hoc Analyses Controlling for BMI
Because of the higher BMI values among categories of overeating, post hoc analyses were conducted to ascertain whether the significant results found between overeating category and weight-related issues (dieting, weight and shape importance) and psychological health (body satisfaction, self-esteem, depressive mood, suicide) could be accounted for by BMI. Inspection of the results indicates that all results remained significant, although were weakened, even after adjusting for BMI.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The first goal of the present study was to assess the prevalence of 4 categories of overeating (no overeating, objective overeating, subclinical binge eating, and binge eating syndrome) among adolescent girls and boys. Overall, 3.1% of girls and 0.9% of boys endorsed criteria for binge eating syndrome, and an additional 14.2% of girls and 6.9% of boys reported objective overeating, regardless of loss of control, frequency, or distress. These prevalence rates are lower than previously published reports of overeating among adolescents.4,5 The discrepant results are likely attributable to differences in the definitions used to assess overeating and binge eating. The definition used in the current study incorporated DSM-IV14 criteria such as embarrassment if others witnessed overeating, loss of control, high frequency, and distress.
The second goal was to identify the associations among overeating and dieting, weight status, body satisfaction, self-esteem, depressive mood, and suicide. Results from the current study support the hypothesis that overeating was associated with higher BMI values and obesity status. It is not surprising that overeating and higher BMI values and obesity are associated in that frequent consumption of large quantities of food is likely to lead to weight gain, notably in the absence of compensatory behaviors typically associated with bulimia nervosa. However, it continues to be unclear how the cycle of dieting, overeating, and obesity starts.
Results from the current study support the hypothesis that overeating was associated with more frequent dieting and greater stress on the importance of weight and shape. Previous studies have found that higher weight is significantly associated with attempts to control weight among adolescents.31 Consistent with another study of adolescent boys and girls,32 overeating and frequent dieting were also associated in the current study, even after controlling for BMI. This finding indicates that the association between overeating and dieting is not solely attributable to the higher BMIs found among those who overeat. In fact, higher BMIs have been found in longitudinal studies of youths who engage in frequent dieting.33,34 It is possible that the association among dieting, overeating, and increased BMI values is based on a chaotic pattern of dieting, feelings of overhunger, loss of control over eating, binge eating, weight gain, and then dieting again, that is consistent with restraint theory. The basic premise of restraint theory for eating behavior is that restrained eating is likely to be a significant risk factor for binge eating35 and may lead to a repeated cycle of dieting and binge eating.
The hypothesis that overeating was associated with compromised psychological health was confirmed. Regardless of which symptom (dieting, overeating, weight gain, and/or concerns about weight and shape) presents first, overeating is associated with body dissatisfaction. Overeating has been found to be associated with body dissatisfaction and drive for thinness among other samples of youths.36 In fact, desire to be thinner was found to be the significant predictor of binge eating in a study of Australian boys and girls.32 It is not clear whether individuals who overeat are dissatisfied with their body as a result of a higher BMI value and/or are dissatisfied with their body because of the lack of control over their body and their eating. However, in the current study, post hoc analyses controlling for BMI were still significant, indicating that the association between overeating and body dissatisfaction is not merely attributable to higher BMI values among those who overeat. Future longitudinal research could evaluate the presence of significant body dissatisfaction in relation to the onset of overeating.
Wertheim et al32 also found that among girls, measures of large current body size, depressed affect, and low self-esteem predicted binge eating. In the current study, girls and boys who reported any level of overeating reported more severe depressive mood and lower self-esteem and were more likely to endorse items about suicidal thoughts and attempts. An unanswered question is whether overeating leads to psychiatric distress, the psychiatric distress precipitates this type of eating,37 or something else is leading to both overeating and compromised psychological health.
The final hypothesis—that those who meet criteria for binge eating syndrome would report the highest rates of weight-related characteristics and highest scores for compromised psychological health and that those who report no overeating would report the lowest rates and lowest scores—was also confirmed. This finding provides justification for the continuum hypothesis of eating disturbance, because youths who engage in objective overeating and subclinical binge eating typically fell in between those who do not overeat and those with binge eating syndrome in terms of weight-related concerns and psychological health. Assuming that youths progress from overeating to more serious forms of overeating such as binge eating syndrome and knowing that youths with binge eating syndrome reported the greatest risks to their physical and psychological health, early detection and intervention of any overeating is clearly warranted.
Several strengths associated with the current study include the large population-based sample of both girls and boys; the more specific definitions of objective overeating, subclinical binge eating, and binge eating syndrome (incorporating DSM-IV diagnostic criteria); and the different measures of psychological distress. Although cross-sectional studies can be very informative, they have limitations in assessing the direction of the influence that variables have on other variables. The validity of self-report assessments is a concern, and future studies may seek to use interviews to increase the validity of youths’ responses. Furthermore, it is possible that other variables, not investigated in the current study, are of influence. Longitudinal data following youths over critical periods during adolescence may help to address causality. When interview methods are not feasible, future studies should consider the use of the adolescent version of the QEWP,6 which now has reliability data,24 to obtain greater confidence in the specificity of overeating among youths. Researchers may want to target specific populations of youths who overeat and binge to compensate for the small number of girls and boys with binge eating syndrome or subclinical binge eating in the current study. The small cell sizes in the current study may limit the ability to detect small but potentially meaningful differences between the subclinical and full-syndrome binge eater groups, especially among specific racial/ethnic groups. Finally, longitudinal data would allow researchers and clinicians to understand whether overeating is a cause or an effect associated with disordered eating behaviors and psychological distress. Knowledge of the precipitants to overeating and the consequences of this eating behavior may help us to identify warning signs to avert significant psychiatric distress. Future longitudinal research should help to identify the order by which the onset of overeating, compared with the onset of body image dissatisfaction, depressive symptoms, low self-esteem, and suicidal thoughts and attempts, occurs.
Suggestions for Professionals
Identify Youths Who Overeat
Because overeating among adolescents is likely to be secretive,6 parents, friends, and professionals may not be aware of the behavior. Professionals who work with children and adolescents should ask about eating behaviors, including restrictive eating and overeating. Because of the increased obesity risk and compromised psychological health associated with overeating, youths who overeat should be targeted for additional intervention regarding weight management and their mental health.
Encourage Healthful Eating and Exercise Lifestyles
In an attempt to combat the chaotic cycle of eating that seems to maintain dieting and overeating, Levine and Marcus38 proposed that professionals should be teaching individuals who overeat to adopt effective weight management strategies and should avoid promotion of restrained eating such as caloric restriction. These strategies include increasing physical activity and fruit and vegetable intake and reducing saturated fat intake. Instruction of healthier weight-management techniques may help to break the chronic cycle of dieting, overeating, and weight gain, and consequently may lead to improved self-esteem.39 These strategies should be provided for all individuals who overeat, regardless of the severity.
Investigate Factors Associated With Overeating Among At-Risk Youths
Youths who overeat may already have or be at increased risk for serious psychological distress, including deficits to self-esteem, compromised mood, and suicide risk. Overeating may be a tangible behavior that signals the need for intervention. When overeating or binge eating is identified, factors that lead to the behavior and potential consequences should be addressed. The depressive mood, low self-esteem, and serious suicide risk associated with overeating, subclinical binge eating, and binge eating syndrome warrants immediate professional attention.
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ACKNOWLEDGMENTS |
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This study was supported by grant MCJ-270834 (to D. Neumark-Sztainer, principal investigator) from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Service Administration, US Department of Health and Human Services.
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FOOTNOTES |
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Received for publication Feb 11, 2002; Accepted May 28, 2002.
Reprint requests to (D.M.A.) 8421 Wayzata Blvd, Ste 305, Golden Valley, MN 55426. E-mail: diann_ackard{at}mindspring.com
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