- Email: [email protected]
59: Relations Among Media Exposure, Internalization, and Body Dissatisfaction for White and Asian-American Females
Abstracts / 42 (2008) S15–S49
school enrollment at 3 mo (Adjusted Odds Ratio [AOR] ⫽ 2.1), DMPA use within 3 mos of delivery (AOR 7.9), continued romantic involvement with father of the baby (AOR 2.9), and having ⱖ 3 people tell adolescent mother she is important (AOR 1.7). Factors predicting pill use include: school enrollment at 3 mo (AOR 1.9), pill use within 3 months of delivery (AOR 3.6), and having ⱖ 3 people tell adolescent mother she is important (AOR 1.9). Together these variables correctly classify 63.3% of all cases, a 25% improvement over chance alone. When 12-month variables are added into the model, concurrent DMPA use is best predicted by school enrollment (AOR 2.2), DMPA use within 3 months of delivery (AOR 7.8), having ⱖ 3 people tell adolescent mother she is important (AOR 1.7), and report of partner allowing adolescent mom to use birth control at 12 mos (0.16). Twelve-month pill use is best predicted by school enrollment (AOR 2.0), pill use within 3 mos of delivery (AOR 4.0), having ⱖ 3 people tell adolescent mother she is important (AOR 2.0), and report of partner allowing adolescent mom to use birth control (AOR 2.3). Addition of 12-mo variables does improve classification (63.5% vs. 63.3%). Conclusion: Factors identified at delivery and at 3 mos later can be used to predict DMPA use and pill use at 12 mos post partum. Encouraging adolescents to use contraception immediately following delivery increases the likelihood of contraceptive use at 12 mos and is improved when adolescents have dyadic and familial support. Of note, report of partner allowing mom to use birth control was negatively associated with DMPA use, but positively associated with pill use. Sources of Support: NIH (DA09636, DA08404), Hogg Foundation for Mental Health (#3777).
SESSION II: ADOLESCENT SELF-IMAGE AND IDENTITY 58. INTEREST IN A MEDICAL CAREER PREDICTS COLLEGE ENROLLMENT AMONG ECONOMICALLY DISADVANTAGED ETHNIC MINORITY STUDENTS Manuel Angel Osco´s-Sa´nchez, MD, L. Dolores Osco´s-Flores, BSEd, Sandra Burge, PhD. Department of Family & Community Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas Purpose: A persistent adolescent health disparity issue in the United States is the underrepresentation of ethnic minority youth in higher medical education. The Teen Medical Academy (TMA) is being implemented with local high school students with the goal of increasing the number of medical school applicants from economically disadvantaged ethnic minority communities. Previous analysis demonstrated that the greater participation in the TMA, involvement in more extracurricular health career programs, higher GPA, and younger age were significantly associated with the attitude outcomes of greater interest, confidence, belongingness, and achievement motivation as related to health careers. In this analysis we examine whether these variables are predictive of college enrollment among the same sample of students. Methods: In the summer of 2006 a self-administered mail survey was conducted with all of the students who applied to the TMA during the first 3 years of the program. Forward stepwise logistic regression analysis, with a dichotomous outcome variable of college enrollment or not, was used to examine the effects of participation in the TMA, other extracurricular health career programs, GPA, age and the attitude variables listed above.
S41
Results: A total of 232 students returned the mail survey (response rate 71%), 43 (19%) were enrolled in college; 213 (92%) were Latino, 8 (3%) were African-American, and 7 (3%) were Native American. The variables that entered the logistic regression model, the odds ratio, and the level of significance are presented in the table below.
Variables that entered the Model
Odds Ratio or Exp (Beta)
Significance
Age Interest in an Allied Health Career Interest in a Medical Career
9.69 0.20 3.00
0.000 0.002 0.032
Conclusions: Among these economically disadvantaged ethnic minority students, those with a higher Interest in a Medical Career were 3 times more likely, while those with a higher Interest in an Allied Health Career were 5 times less likely to enroll in college. Health career opportunity programs such as the Teen Medical Academy should continue to stimulate students’ Interest in a Medical Career as it positively influences college enrollment. However, there is also a need to increase students’ awareness that careers in Allied Health require college enrollment. Source of Support: Texas Higher Education Coordinating Board.
59. RELATIONS AMONG MEDIA EXPOSURE, INTERNALIZATION, AND BODY DISSATISFACTION FOR WHITE AND ASIAN-AMERICAN FEMALES Mahsa Nouri, BA, Joan K. Orrell-Valente, PhD Purpose: Body dissatisfaction is a key risk factor for the development of eating disorders. Although media exposure is associated with body dissatisfaction for White females who subscribe to, or internalize, the Western thin-ideal, little is known about these associations for Asian-Americans, one of the fastest-growing yet least studied U.S. minority groups. To our knowledge, this is the first study to compare the associations between (1) media exposure and body dissatisfaction, and (2) media exposure and internalization of the thin-ideal, for Whites and Asian college females. Moreover, (3) we tested the hypothesis that, as with Whites, internalization of the Western thin-ideal mediates the association between media exposure and body dissatisfaction for AsianAmericans. Methods: Participants were 289 college undergraduate females (44.5% White; 52.2% Asian) who completed surveys. Groups did not differ on age (mean 20.48, SD ⫽ 1.52) or body mass index (mean 21.98, SD ⫽ 3.43). We used hierarchical regression to test associations. Results: Magazine exposure, but not TV exposure, was significantly associated with body dissatisfaction (p ⬍ 0.01) and with internalization of the thin-ideal (p ⬍ 0.001) for Whites and Asians. As hypothesized, aspects of internalization of the thin-ideal mediated the association between magazine exposure and body dissatisfaction in both groups. Specifically, for Whites, the relation between media exposure and body dissatisfaction was explained in part by perceived pressure to conform to the thin-ideal (p ⬍ 0.001), one key aspect of thin-ideal internalization. In the Asian group, however, two key aspects of internalization were found to partly account for the media exposure-body dissatisfaction relation: perceived pressure to conform to the thin-ideal (p ⬍ 0.001) and internalization of the media-prescribed athletic ideal (p ⬍ 0.01).
S42
Abstracts / 42 (2008) S15–S49
Conclusions: Ethnicity and culture do not seem to protect against the influence of Western media exposure for Asian females. The results suggest that Asian-American young women are as vulnerable to the development of eating disorders as their White peers. It is likely, however, that this risk often goes undetected because of stereotypical perceptions that Asians are the “model minority” or because Asian women are thought to be naturally thin (Lau et al., 2006). Research has shown, for example, that Asian-American women who use laxatives are significantly less likely to be recommended for clinical evaluation (Franko et al., 2007). Clinicians serving this population should be cognizant of this risk and should treat appropriately. In addition, future research is warranted on treatment approaches that are most effective for this population. Sources of Support: UC Berkeley Research Participation Program (RPP).
60. THE SEXUAL IDENTITY OF ADOLESCENTS AND YOUNG ADULTS: WHIMSY OR UNITARY PHENOMENON? Gary Remafedi, MD, MPH, Anne M. Jurek, PhD, J. Michael Oakes, PhD. Department of Pediatrics & School of Public Health, University of Minnesota, Minneapolis, Minnesota Purpose: Understand the development, key components, and changes in sexual identity (SI) during adolescence and young adulthood. Methods: Cross-sectional survey of 13-24 year-old persons systematically selected by time-space sampling for face-to-face interviews from venues in a large metropolitan area. The main outcomes were: SI (i.e., self-identified sexual orientation [SO] as rated on a 5-point Likert scale); recollected age at the time of attaining 7 milestones in SI development; and Klein “SO Grid” (comprised of 7 dimensions, each self-rated on a 7-point Likert scale in relation to the last year and more than one year ago). The designated level of statistical significance was p ⬍ 0.05. Results: A total of 77% (500/653) of eligible participants completed surveys, including 239 self-identified males (129 heterosexual [Ht], 20 bisexual [Bi], 90 homosexual [Hm]) and 259 females (146 Ht, 58 Bi, 55 Hm). Mean age was 20.3 (SD ⫽ 2.4) years. Given more than one option, 66.6% (N ⫽ 333) identified as White; 22.0% (N ⫽ 110), Black or African-American; 7.0% (N ⫽ 35), Asian/ Pacific Islander; 1.8% (N ⫽ 9), Native-American; 9.4 % (N ⫽ 47), “other”; and two refused. SI was differently distributed for females and males [Chi square value 33.9, df ⫽ 4, p ⬍ 0.0001]. More females identified as Bi (22.4 v. 8.4%); and more males, as exclusively Hm (25.5 v. 12.7%). Awareness of sexual attractions preceded SO identification, sexual debut, and disclosure of SI in all groups of Ht, Bi, and Hm males and females. Based on one-way ANOVA and post hoc Scheffe’s tests, Ht females and males became aware of their attractions and SI at significantly younger ages than Hm females and males. Gender-stratified bivariate logistic regression analyses revealed that Ht, Bi, Hm groups rated almost every dimension of SO differently. Same-sex attraction was the strongest correlate of SI in females (Hm v Ht OR: 12.7 [95% CI: 6.9,23.4]) and males (Hm v Ht OR: 276.0 [95% CI: 43.9,1734.5]). Same-sex emotional “closeness” (Hm v. Ht OR: 4.1 [95% CI: 2.8,6.0]) also was associated with SI in females. Totals of 57.5% to 68.8% females and 61.4% to 82.8% of males reported no change in the last year on any dimension of SO; and the mean change within groups generally was less than 0.5 in the Hm direction on each of the Klein 7-point Likert-scale items.
Conclusions: Regardless of its trajectory in the same- or oppositesex direction, SI development followed a predictable course from early sexual attractions to SO identification, sexual behavior, and disclosure (if any) to friends and parents. SI was differently distributed among females and males, and Hm and Bi youth recalled reaching milestones at older ages than Ht peers. Pending prospective longitudinal study, SI can be seen as a unitary phenomenon with conceptually consistent dimensions, propelled by sexual attraction and unfolding during adolescence. Source of Support: Grant Number RC-2003-0002 from ClearWay Minnesota.
61. THE ASSOCIATION OF ANXIETY AND DEPRESSIVE SYMPTOMS WITH OBESITY AMONG ADOLESCENT FEMALES: LOOKING BEYOND BODY MASS INDEX Jennifer B. Hillman, MD, Bin Huang, PhD, Lorah D. Dorn, PhD. Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio Purpose: To evaluate the association between anxiety and depressive symptoms and obesity among adolescent females using different measures for obesity. As secondary aims we explored whether these associations differed by race, and looked for differences in obesity measures between groups with normal and high depressive symptom scores. Methods: Cross sectional analysis of 207 females ages 11, 13, 15, and 17 years (mean 14.0, SD 2.2) recruited from an outpatient teen health center and the surrounding community. Symptoms of trait anxiety were measured using Spielberger State-Trait Inventory for Children (STAIC) and depressive symptoms were measured with the Children’s Depression Inventory (CDI). T-scores (mean ⫽ 50; SD ⫽ 10) were used in the analysis. The outcome measures included three methods to assess obesity: body mass index (BMI) z-score, percent body fat from dual energy x-ray absorptiometry (DEXA), and fat distribution derived from the ratio of the fat mass in upper verses the lower regions of the body from DEXA (similar to a waist to hip ratio). General linear regression was used. Mean differences (t-tests) for obesity were compared between adolescents with normal and high depressive symptoms. Results: All regression models controlled for age, race, socioeconomic status, Tanner stage for breast, and smoking status. Anxiety and depressive symptoms were not significantly associated with BMI z-score. Both anxiety and depressive symptoms were positively associated with percent body fat. For anxiety, an increase of ten points on the STAIC resulted in 1.70 increase in percent body fat (p ⫽ 0.009). For depressive symptoms, an increase of ten points on the CDI resulted in 1.24 increase in percent body fat (p ⫽ 0.021). Subgroup analysis of White verses nonWhite subjects revealed the association between depressive symptoms with percent body fat was significant only for Whites (p ⫽ 0.028). Depressive symptoms were significantly associated with fat distribution (p ⫽ 0.027) but after controlling for the above covariates, the association was no longer significant. Similar results were seen for symptoms of anxiety and fat distribution. Comparison of the means for BMI z-score, percent body fat, and fat distribution among those with normal CDI T-score (n ⫽ 163) and those with high CDI T-score (n ⫽ 36) revealed a significant difference for percent body fat (t ⫽ 2.58, p ⫽ 0.01) where the high CDI group had higher percent body fat. There was no difference between groups for BMI z-score or fat distribution.
school enrollment at 3 mo (Adjusted Odds Ratio [AOR] ⫽ 2.1), DMPA use within 3 mos of delivery (AOR 7.9), continued romantic involvement with father of the baby (AOR 2.9), and having ⱖ 3 people tell adolescent mother she is important (AOR 1.7). Factors predicting pill use include: school enrollment at 3 mo (AOR 1.9), pill use within 3 months of delivery (AOR 3.6), and having ⱖ 3 people tell adolescent mother she is important (AOR 1.9). Together these variables correctly classify 63.3% of all cases, a 25% improvement over chance alone. When 12-month variables are added into the model, concurrent DMPA use is best predicted by school enrollment (AOR 2.2), DMPA use within 3 months of delivery (AOR 7.8), having ⱖ 3 people tell adolescent mother she is important (AOR 1.7), and report of partner allowing adolescent mom to use birth control at 12 mos (0.16). Twelve-month pill use is best predicted by school enrollment (AOR 2.0), pill use within 3 mos of delivery (AOR 4.0), having ⱖ 3 people tell adolescent mother she is important (AOR 2.0), and report of partner allowing adolescent mom to use birth control (AOR 2.3). Addition of 12-mo variables does improve classification (63.5% vs. 63.3%). Conclusion: Factors identified at delivery and at 3 mos later can be used to predict DMPA use and pill use at 12 mos post partum. Encouraging adolescents to use contraception immediately following delivery increases the likelihood of contraceptive use at 12 mos and is improved when adolescents have dyadic and familial support. Of note, report of partner allowing mom to use birth control was negatively associated with DMPA use, but positively associated with pill use. Sources of Support: NIH (DA09636, DA08404), Hogg Foundation for Mental Health (#3777).
SESSION II: ADOLESCENT SELF-IMAGE AND IDENTITY 58. INTEREST IN A MEDICAL CAREER PREDICTS COLLEGE ENROLLMENT AMONG ECONOMICALLY DISADVANTAGED ETHNIC MINORITY STUDENTS Manuel Angel Osco´s-Sa´nchez, MD, L. Dolores Osco´s-Flores, BSEd, Sandra Burge, PhD. Department of Family & Community Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas Purpose: A persistent adolescent health disparity issue in the United States is the underrepresentation of ethnic minority youth in higher medical education. The Teen Medical Academy (TMA) is being implemented with local high school students with the goal of increasing the number of medical school applicants from economically disadvantaged ethnic minority communities. Previous analysis demonstrated that the greater participation in the TMA, involvement in more extracurricular health career programs, higher GPA, and younger age were significantly associated with the attitude outcomes of greater interest, confidence, belongingness, and achievement motivation as related to health careers. In this analysis we examine whether these variables are predictive of college enrollment among the same sample of students. Methods: In the summer of 2006 a self-administered mail survey was conducted with all of the students who applied to the TMA during the first 3 years of the program. Forward stepwise logistic regression analysis, with a dichotomous outcome variable of college enrollment or not, was used to examine the effects of participation in the TMA, other extracurricular health career programs, GPA, age and the attitude variables listed above.
S41
Results: A total of 232 students returned the mail survey (response rate 71%), 43 (19%) were enrolled in college; 213 (92%) were Latino, 8 (3%) were African-American, and 7 (3%) were Native American. The variables that entered the logistic regression model, the odds ratio, and the level of significance are presented in the table below.
Variables that entered the Model
Odds Ratio or Exp (Beta)
Significance
Age Interest in an Allied Health Career Interest in a Medical Career
9.69 0.20 3.00
0.000 0.002 0.032
Conclusions: Among these economically disadvantaged ethnic minority students, those with a higher Interest in a Medical Career were 3 times more likely, while those with a higher Interest in an Allied Health Career were 5 times less likely to enroll in college. Health career opportunity programs such as the Teen Medical Academy should continue to stimulate students’ Interest in a Medical Career as it positively influences college enrollment. However, there is also a need to increase students’ awareness that careers in Allied Health require college enrollment. Source of Support: Texas Higher Education Coordinating Board.
59. RELATIONS AMONG MEDIA EXPOSURE, INTERNALIZATION, AND BODY DISSATISFACTION FOR WHITE AND ASIAN-AMERICAN FEMALES Mahsa Nouri, BA, Joan K. Orrell-Valente, PhD Purpose: Body dissatisfaction is a key risk factor for the development of eating disorders. Although media exposure is associated with body dissatisfaction for White females who subscribe to, or internalize, the Western thin-ideal, little is known about these associations for Asian-Americans, one of the fastest-growing yet least studied U.S. minority groups. To our knowledge, this is the first study to compare the associations between (1) media exposure and body dissatisfaction, and (2) media exposure and internalization of the thin-ideal, for Whites and Asian college females. Moreover, (3) we tested the hypothesis that, as with Whites, internalization of the Western thin-ideal mediates the association between media exposure and body dissatisfaction for AsianAmericans. Methods: Participants were 289 college undergraduate females (44.5% White; 52.2% Asian) who completed surveys. Groups did not differ on age (mean 20.48, SD ⫽ 1.52) or body mass index (mean 21.98, SD ⫽ 3.43). We used hierarchical regression to test associations. Results: Magazine exposure, but not TV exposure, was significantly associated with body dissatisfaction (p ⬍ 0.01) and with internalization of the thin-ideal (p ⬍ 0.001) for Whites and Asians. As hypothesized, aspects of internalization of the thin-ideal mediated the association between magazine exposure and body dissatisfaction in both groups. Specifically, for Whites, the relation between media exposure and body dissatisfaction was explained in part by perceived pressure to conform to the thin-ideal (p ⬍ 0.001), one key aspect of thin-ideal internalization. In the Asian group, however, two key aspects of internalization were found to partly account for the media exposure-body dissatisfaction relation: perceived pressure to conform to the thin-ideal (p ⬍ 0.001) and internalization of the media-prescribed athletic ideal (p ⬍ 0.01).
S42
Abstracts / 42 (2008) S15–S49
Conclusions: Ethnicity and culture do not seem to protect against the influence of Western media exposure for Asian females. The results suggest that Asian-American young women are as vulnerable to the development of eating disorders as their White peers. It is likely, however, that this risk often goes undetected because of stereotypical perceptions that Asians are the “model minority” or because Asian women are thought to be naturally thin (Lau et al., 2006). Research has shown, for example, that Asian-American women who use laxatives are significantly less likely to be recommended for clinical evaluation (Franko et al., 2007). Clinicians serving this population should be cognizant of this risk and should treat appropriately. In addition, future research is warranted on treatment approaches that are most effective for this population. Sources of Support: UC Berkeley Research Participation Program (RPP).
60. THE SEXUAL IDENTITY OF ADOLESCENTS AND YOUNG ADULTS: WHIMSY OR UNITARY PHENOMENON? Gary Remafedi, MD, MPH, Anne M. Jurek, PhD, J. Michael Oakes, PhD. Department of Pediatrics & School of Public Health, University of Minnesota, Minneapolis, Minnesota Purpose: Understand the development, key components, and changes in sexual identity (SI) during adolescence and young adulthood. Methods: Cross-sectional survey of 13-24 year-old persons systematically selected by time-space sampling for face-to-face interviews from venues in a large metropolitan area. The main outcomes were: SI (i.e., self-identified sexual orientation [SO] as rated on a 5-point Likert scale); recollected age at the time of attaining 7 milestones in SI development; and Klein “SO Grid” (comprised of 7 dimensions, each self-rated on a 7-point Likert scale in relation to the last year and more than one year ago). The designated level of statistical significance was p ⬍ 0.05. Results: A total of 77% (500/653) of eligible participants completed surveys, including 239 self-identified males (129 heterosexual [Ht], 20 bisexual [Bi], 90 homosexual [Hm]) and 259 females (146 Ht, 58 Bi, 55 Hm). Mean age was 20.3 (SD ⫽ 2.4) years. Given more than one option, 66.6% (N ⫽ 333) identified as White; 22.0% (N ⫽ 110), Black or African-American; 7.0% (N ⫽ 35), Asian/ Pacific Islander; 1.8% (N ⫽ 9), Native-American; 9.4 % (N ⫽ 47), “other”; and two refused. SI was differently distributed for females and males [Chi square value 33.9, df ⫽ 4, p ⬍ 0.0001]. More females identified as Bi (22.4 v. 8.4%); and more males, as exclusively Hm (25.5 v. 12.7%). Awareness of sexual attractions preceded SO identification, sexual debut, and disclosure of SI in all groups of Ht, Bi, and Hm males and females. Based on one-way ANOVA and post hoc Scheffe’s tests, Ht females and males became aware of their attractions and SI at significantly younger ages than Hm females and males. Gender-stratified bivariate logistic regression analyses revealed that Ht, Bi, Hm groups rated almost every dimension of SO differently. Same-sex attraction was the strongest correlate of SI in females (Hm v Ht OR: 12.7 [95% CI: 6.9,23.4]) and males (Hm v Ht OR: 276.0 [95% CI: 43.9,1734.5]). Same-sex emotional “closeness” (Hm v. Ht OR: 4.1 [95% CI: 2.8,6.0]) also was associated with SI in females. Totals of 57.5% to 68.8% females and 61.4% to 82.8% of males reported no change in the last year on any dimension of SO; and the mean change within groups generally was less than 0.5 in the Hm direction on each of the Klein 7-point Likert-scale items.
Conclusions: Regardless of its trajectory in the same- or oppositesex direction, SI development followed a predictable course from early sexual attractions to SO identification, sexual behavior, and disclosure (if any) to friends and parents. SI was differently distributed among females and males, and Hm and Bi youth recalled reaching milestones at older ages than Ht peers. Pending prospective longitudinal study, SI can be seen as a unitary phenomenon with conceptually consistent dimensions, propelled by sexual attraction and unfolding during adolescence. Source of Support: Grant Number RC-2003-0002 from ClearWay Minnesota.
61. THE ASSOCIATION OF ANXIETY AND DEPRESSIVE SYMPTOMS WITH OBESITY AMONG ADOLESCENT FEMALES: LOOKING BEYOND BODY MASS INDEX Jennifer B. Hillman, MD, Bin Huang, PhD, Lorah D. Dorn, PhD. Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio Purpose: To evaluate the association between anxiety and depressive symptoms and obesity among adolescent females using different measures for obesity. As secondary aims we explored whether these associations differed by race, and looked for differences in obesity measures between groups with normal and high depressive symptom scores. Methods: Cross sectional analysis of 207 females ages 11, 13, 15, and 17 years (mean 14.0, SD 2.2) recruited from an outpatient teen health center and the surrounding community. Symptoms of trait anxiety were measured using Spielberger State-Trait Inventory for Children (STAIC) and depressive symptoms were measured with the Children’s Depression Inventory (CDI). T-scores (mean ⫽ 50; SD ⫽ 10) were used in the analysis. The outcome measures included three methods to assess obesity: body mass index (BMI) z-score, percent body fat from dual energy x-ray absorptiometry (DEXA), and fat distribution derived from the ratio of the fat mass in upper verses the lower regions of the body from DEXA (similar to a waist to hip ratio). General linear regression was used. Mean differences (t-tests) for obesity were compared between adolescents with normal and high depressive symptoms. Results: All regression models controlled for age, race, socioeconomic status, Tanner stage for breast, and smoking status. Anxiety and depressive symptoms were not significantly associated with BMI z-score. Both anxiety and depressive symptoms were positively associated with percent body fat. For anxiety, an increase of ten points on the STAIC resulted in 1.70 increase in percent body fat (p ⫽ 0.009). For depressive symptoms, an increase of ten points on the CDI resulted in 1.24 increase in percent body fat (p ⫽ 0.021). Subgroup analysis of White verses nonWhite subjects revealed the association between depressive symptoms with percent body fat was significant only for Whites (p ⫽ 0.028). Depressive symptoms were significantly associated with fat distribution (p ⫽ 0.027) but after controlling for the above covariates, the association was no longer significant. Similar results were seen for symptoms of anxiety and fat distribution. Comparison of the means for BMI z-score, percent body fat, and fat distribution among those with normal CDI T-score (n ⫽ 163) and those with high CDI T-score (n ⫽ 36) revealed a significant difference for percent body fat (t ⫽ 2.58, p ⫽ 0.01) where the high CDI group had higher percent body fat. There was no difference between groups for BMI z-score or fat distribution.