Do physicians discuss needed diet and nutrition health topics with adolescents?

Journal of Adolescent Health 38 (2006) 608.e1– 608.e6

Original article

Do physicians discuss needed diet and nutrition health topics with adolescents? Jonathan D. Klein, M.D., M.P.H.a,b,*, Corinne K. Postlea, Richard E. Kreipe, M.D.a, Shannon M. Smitha, Scott McIntosh, Ph.D.b,c, Jean Spada, M.P.H.b,c, and Deborah Ossip-Klein, Ph.D.b,c a

b

Department of Pediatrics, University of Rochester School of Medicine, Rochester, New York Department of Community and Preventive Medicine, University of Rochester School of Medicine, Rochester, New York c James P. Wilmot Cancer Center, University of Rochester School of Medicine, Rochester, New York Manuscript received September 29, 2004; manuscript accepted June 7, 2005

Abstract

Purpose: Preventive services guidelines recommend screening all adolescents for diet habits, physical activity and growth, counseling underweight teens about body image and dieting patterns, and counseling overweight or obese teens about dietary habits and exercise. In this study, we assess whether adolescents at risk for overweight or for eating disorders have discussed recommended diet and nutrition topics with their physicians. Methods: We surveyed 14 –18-year-old adolescents who had been seen for well care in primary care pediatric and family medicine practices. Adolescents self-reported their weight, height, body image, dieting habits, and issues they had discussed with their clinicians. Body mass index (BMI) was used to define those “at risk for an eating disorder” (⬍ 5% BMI), “at risk of becoming overweight” (85%–95% BMI), and “overweight” (⬎ 95% BMI). Results: A total of 8384 adolescents completed surveys (72% completion rate). Nearly one-third of adolescents were “at risk” or overweight. Females were less likely to be overweight than males (9.4% vs. 15.7%; p ⬍ .001). Although 26.4% were attempting to lose weight, only 12.2% of all teens were actually overweight. Exercise and restricting intake were the preferred methods of weight loss. Physicians routinely discussed adolescents’ weight during visits, and were more likely to discuss it with those “at risk” (p ⬍ .001). Body image was more often discussed with girls than with boys (52% vs. 44.6%, p ⬍ .001) and with those at risk (51.6% vs. 45.5%; p ⬍ .001). Discussion of healthy eating and weight loss occurred more often with adolescents “at risk” for becoming overweight (p ⬍ .001). Conclusions: Many adolescents are at risk for being overweight or are currently overweight, confirming the importance of clinicians discussing diet and nutrition health topics with all teens. Many adolescents also misclassify their body image, and hence perceive their body image to be different from their actual BMI; clinicians should discuss body image with all adolescents, not just those at risk for eating disorders. Better interventions are needed to promote healthy nutrition and physical activity to all adolescents. © 2006 Society for Adolescent Medicine. All rights reserved.

Keywords:

Prevention; Overweight; Obesity; Physician counseling; Guidelines

Currently there is a growing trend in the rise of obesity and eating disorders in the United States [1,2]. Adolescent *Address correspondence to: Dr. Jonathan D. Klein, Division of Adolescent Medicine, 601 Elmwood Ave., Box 690, Rochester, NY 14642. E-mail address: [email protected]

obesity increased from 5% to 10.5% in 1988 –1994 to 15.5% in 1999 –2000 [3]. Although obesity may be related to genetics and other medical problems [4], obesity is partially the result of environmental and social factors, such as increased sedentary lifestyles. According to the National Health and Nutrition Examination Survey (NHANES), 43%

1054-139X/06/$ – see front matter © 2006 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2005.06.009

608.e2

J.D. Klein et al. / Journal of Adolescent Health 38 (2006) 608.e1– 608.e6

of adolescents reported watching two or more hours of television each day [5], less than 50% of adolescents reported regular vigorous physical activity, and one-fourth reported no vigorous physical activity [5]. Obesity increases one’s risk of developing cardiovascular disease, Type 2 diabetes, high blood pressure, and some types of cancer as an adult [5]. Even being slightly overweight for either gender decreases adult lifespan [6], and recent studies have shown an association between depression and obesity [7]. Nationally, 15.5% of America’s adolescents are overweight, and about 5% of adolescents suffer from eating disorders [8]. Eating disorders in adolescence can result in both immediate and future health consequences. Many deleterious health problems such as bone fractures, osteoporosis, amenorrhea, short stature, cardiovascular and gastrointestinal complications, depression and low self-esteem can continue to affect adolescents with eating disorders into adulthood [8,9]. Body image, a multidimensional construct, is a measure of how people define their self-worth, self-esteem, and selfconcept [10]. Eating disorders in adolescents are partly associated with having poor body images and with health consequences. Those individuals who are overweight or obese are also at risk of having a poor body image [11]. With other factors such as gender, age, culture, and media exposure, a poor body image can escalate and result in an eating disorder [12,13]. If physicians and other clinicians assess adolescents who may be at risk for developing either of these health problems, they may be able to promote healthier lifestyles for adolescents in the context of environment, behavior, family and dietary habits [14,15]. However, primary care clinicians identify barriers to delivery of nutrition guidance, including lack of belief in their ability to influence the patient’s lifestyles and eating habits, lack of interest in nutrition health by physicians, lack of confidence in ability to give dietary recommendations, and perception that behavior and heredity are the only factors that can affect their patients’ health status [15]. Very little is known regarding the counseling clinicians provide adolescents concerning diet and nutrition, or how well clinicians identify adolescents at risk for both eating disorders and obesity. This study assesses whether adolescents who are “at risk” for becoming overweight or developing an eating disorder have discussed recommended diet and nutrition health topics with their clinicians. Methods Subjects Adolescents aged 14 –18 years from a six-county area in western New York who were being seen for preventive visits at pediatric and family medicine practices were given

the opportunity to enroll in a health survey at the time of their visit, as part of a group randomized trial of smoking cessation counseling for youth. Practice site recruitment was presented to 103 pediatric and family primary care practices, of which 101 (98%) agreed to participate. Adolescents at these practices were recruited using a release-ofinformation form that was faxed to the research team, and parents and adolescents were then called for consent. All adolescents being seen for well visits were offered enrollment in the survey, regardless of smoking status, and adolescents received a $5 gift card upon completion of the survey. The research protocol was approved by the University of Rochester Subjects Research Review Board. Of the adolescents seen in these practices between May 2000 and September 2002, 11,659 (58.5%) agreed to be contacted, and 8384 of these (71.9%) completed telephone interviews. Health survey Telephone surveys were conducted with participating adolescents after well visits. Adolescents were asked a range of health-related questions, including self-reported weight, height, activity level, television habits, body image, changes with their bodies, how they feel about their body, dieting, and exercise habits. They were also queried about what health topics their clinician discussed with them at the well visit. Survey items were adapted from the Centers for Disease Control (CDC) Youth Risk Behavior Survey, and from other studies of primary care counseling delivery to adolescents. All items were evaluated using in-depth cognitive interviews and field piloted with a convenience sample of youth in primary care clinics at the University of Rochester. Anthropometry Self-reported height and weight were used to calculate the adolescents’ body mass index (BMI ⫽ Wt(kg)/Ht(m2). Adolescents were said to have a misclassification of their body image if their perception of themselves as being underweight, normal, or overweight differed from their actual category based on their BMI. Definition of “at risk” Using age, gender, and BMI standards from the CDC [16] and risk/screening criteria from the American Medical Association Guidelines for Adolescent Preventive Services [17], we defined adolescents as “at risk for an eating disorder” if they were ⬍ 5% percentile for BMI, “at risk of becoming overweight” if they were 85%–95% percentile for BMI, and overweight if they were ⬎ 95% percentile for BMI.

J.D. Klein et al. / Journal of Adolescent Health 38 (2006) 608.e1– 608.e6

Table 2 Percent of adolescents within each BMI category by demographics

Statistical methods All statistical analysis was performed using SPSS (SPSS Inc., Chicago, Illinois). Chi-square analysis and t-tests were used to analyze the data. Results A total of 8384 adolescents were enrolled. The average age was 15.5 years (SD ⫾ 1.3); 56.9% of respondents were females and 87.2% were of white, non-Hispanic ethnicity (Table 1). Overall, 29% of the adolescents, based on their selfreported BMI, were classified as “at risk.” This includes those individuals who were “at risk” for an eating disorder, “at risk” for becoming overweight, or were overweight. In this population, BMI increased with age. However, the proportion of respondents who were “at risk” for becoming overweight or were overweight decreased slightly with increasing age (Table 2). Compared with the white population, more black, American Indian, and Hispanic adolescents were “at risk” for overweight. Hispanic and Black populations also had higher rates of actually being overweight. Overall, 32% of males and 24% of females were “at risk” for being overweight. Only 1.5% of males and 1.1% of females were at risk for developing an eating disorder. In general, most adolescents reported having discussed topics such as weight, changes with their body, healthy eating, how they feel about their body, exercise, and diet/ Table 1 Description of participants

Sex All Male Female Age (years) 14 15 16 17 18 Ethnicity/race White Black Hispanic Asian American Indian Other Grade 7 8 9 10 11 12 College freshman Other

608.e3

n

% of total population

Mean BMI

8382 3623 4759

100 43.2 56.8

22.78 23.07 22.56

2365 2100 1703 1449 767

28.2 25 20.3 17.3 9.1

21.97 22.84 23.07 23.31 23.40

7305 652 298 192 136 105

87.1 7.8 3.6 2.3 1.6 1.2

22.63 24.41 24.05 23.89 22.09 23.99

60 970 2243 1911 1499 1387 175 128

.7 11.6 26.8 22.8 17.9 16.5 2.1 1.6

22.78 21.92 22.40 22.98 23.00 23.31 23.36 23.20

Actual BMI percentile

Total # of respondents Gender* Females Males Age* 14 15 16 17 18 Ethnicity White Black** Hispanic** American Indian*** Asian Other

⬍5th

5th–85th

85th–95th

⬎95th

1.3

71.3

15.3

12.2

1.1 1.5

75 66.5

14.4 16.4

9.4 15.7

.9 1.3 .9 1.9 2.4

68.9 68.6 72.7 74.9 75.8

17.8 16.1 14.5 12.2 12.8

12.4 14.0 11.9 11.1 9.0

1.3 1.4 .4 .8 1.6 1

73 55.9 61.5 63.1 75.8 64.7

14.8 19.8 15.6 18.5 14 19.6

10.8 22.9 22.5 17.7 8.6 14.7

* p ⬍ .01. ** vs. non-Hispanic Whites, p ⬍ .01. *** vs. non-Hispanic Whites, p ⬍ .05.

weight loss with their clinician (Table 3). Discussion concerning weight issues occurred in 76.6% of the sample. Overall, weight discussions occurred significantly more often with overweight adolescents than for those with BMIs in the normal range (p ⬍ .01). Although males had a higher rate of being “at risk,” discussion with their clinicians concerning weight occurred more often for females (58.4% vs.

Table 3 Percent of adolescents within each BMI category that discussed these topics Actual BMI percentile

Female Weight Exercise Changes w/body Healthy eating Feel about body Diet/weight loss Male Weight Exercise Changes w/body Healthy eating Feel about body Diet/weight loss

⬍5th

5th–85th

85th–95th

⬎95th

83.0 81.1 69.8 81.1 56.6 32

79.5* 83.8* 57.6 75.4*** 49.5*** 35.6***

79.4 86.3 55.2 78.1 55.2 53.4***

88.2*** 87.7* 58.9 85.4*** 58.9 72.4***

79.6 77.8 44.4 64.8 44.4 11.1*

72.9*** 81.7 48*** 65.4*** 44.9 18.8***

75.2 82.9 43.2 66.8 43.0 28.0

84.3*** 84.3 46.4** 77.7*** 49.9* 56.4***

p values calculated from ␹2 to compare indicated BMI category with all other BMI categories. * p ⬍ .05. ** p ⬍ .01. *** p ⬍ .001.

608.e4

J.D. Klein et al. / Journal of Adolescent Health 38 (2006) 608.e1– 608.e6 Table 4 Accuracy of adolescent’s assessment of their weight status Actual BMI percentile

Self-report of weight status Very underweight

Slightly underweight

Normal

Slightly overweight

Very overweight

⬍5th 5th–85th 85th–95th ⬎95th

16.8% 1.0% .0% .2%

47.7% 15.8% 1.3% .4%

28% 71.7% 49.0% 16.2%

7.5% 11.4% 47.8% 63.0%

0% .2% 2.0% 20.2%

41.5%, p ⬍ .01). Discussions also took place more often with black adolescents, who had the highest rates of being overweight, or “at risk” of overweight; black adolescents were also more likely to have discussed weight with their clinicians (p ⬎ .05). Younger adolescents were also more likely to have discussed weight than were older adolescents (p ⬍ .01). Discussions concerning exercise/physical activity occurred more often than any other topics. On average, clinicians discussed exercise with 83% of the adolescents. Clinicians were also more likely to discuss diet, weight loss, and physical activity/exercise with adolescents as BMIs increased, and were more likely to discuss diet and weight loss with overweight females (72.4%). Overweight males were almost twice as likely to discuss diet and weight loss with their clinician compared with males who were only “at risk” for being overweight (56.1% vs. 28.1%; p ⬍ .01). Body image and weight loss attempts/methods Nearly one-third of all adolescents had misclassified their body image, in that their perceived body image differed from their actual BMI. Underweight adolescents were more likely to over-report their weight status and normal and overweight adolescents were more likely to underreport their weight (Table 4). Males had higher rates of misclassification of their body image than females. Overall, 65.9% of females and 34.1% of males reported weight loss attempts. Exercise and restricting foods, calories, and fats were the most common methods (Table 5). Overweight females had the highest rates of reported attempted use of all weight loss methods. On average, males engaged in more hard physical activity (at least 20 minutes of an activity that made one breathe hard and sweat) than females (4.7 days/week vs. 3.9 days/week; p ⬍ .01). Among the 76% of females with a normal or below normal BMI, 32.8% reported weight loss attempts within the past 30 days. In contrast, only 20% of male population with normal or below normal BMIs reported weight loss attempts. Discussion This study is one of the first to examine physicians’ practices with regard to nutritional screening from adolescent patients’ perspectives. Almost 28% of the adolescents

seen during well visits in these primary care settings were “at risk” for being overweight or were overweight. Counseling concerning weight and healthy eating occurred in almost 80% of these encounters, based on adolescents’ reports. Nonetheless, there were many adolescents who were at risk for becoming overweight or who were overweight who did not receive information about this aspect of their health. Overall, we found that clinicians discussed weight and healthy eating with most adolescents, which is consistent with past research that found preventive counseling concerning weight and nutrition had the highest rates of discussion [18]. The higher rates of discussions concerning weight and healthy eating with female patients in our sample could be the result of past literature reporting higher rates of “at risk” for becoming overweight among women [5]. In addition, young women often have higher rates of weight concerns [19,20], and therefore, primary care physicians may perceive their gender as a risk factor and thus choose to discuss these issues more with them. In fact, more males in our sample were found to be at risk for overweight, and they actually received less counseling. This suggests the need for clinicians to discuss diet and nutrition topics with

Table 5 Percent of adolescents in each weight category and reported methods used in past 30 days to lose weight or keep from gaining weight Actual BMI percentile

Exercise Overall Female Male Restrict food, calories, or fat Overall Female Male Fast for 24 hrs or more Overall Female Male Use diet pills, powders, or liquids Overall Female Male

⬍5th

5th–85th

85th–95th

⬎95th

6.5 7.5 5.6

30.7 38.7 19.0

62.5 72.8 50.8

79.6 83.8 76.3

2.8 3.8 1.9

19.4 26.5 8.9

46.1 58.4 32.1

65.6 74.0 59.0

.9 .5 0

2.4 3.2 1.1

3.1 4.8 1.2

5.5 8.4 3.2

.9 0 1.9

.9 1.3 .2

1.9 3.0 0.7

2.7 3.9 1.8

J.D. Klein et al. / Journal of Adolescent Health 38 (2006) 608.e1– 608.e6

both adolescent males and females, especially with those adolescents who are “at risk” for future health consequences. We found that 29% of our sample was in an “at risk” category. Black and Hispanic adolescents were more likely to be “at risk” for becoming overweight than any other ethnic group, and minority teens were more likely to have discussed weight with their physicians than were white teens. We cannot tell from this data why minorities received more counseling, however, their increased prevalence of obesity may have contributed to higher counseling rates. Other studies also find greater obesity among ethnic minority adolescents [3]. Obese adolescents had the greatest rates of exercise and weight loss counseling; not surprisingly, those who were classified as “at risk” for an eating disorder received the least amount of counseling on these issues. However, these adolescents may equally be at risk for future health complications as those with high BMI. Dieting and attempts to lose weight can be the initial steps in developing eating disorders [21]. The higher rates of discussion with overweight adolescents may be due to trends that demonstrate increasing rates of obesity and to the fact that being overweight is an obvious, visible diagnosis. In addition, many clinicians are less aware of the consequences of eating disorders or of the opportunities for prevention [22–24]. Because a third of the adolescents misclassify their body weight/image and a significant percentage of “normal” and underweight teens want to or try to lose weight, clinicians may need to explore how adolescents feel about their bodies during health care encounters. In the past, females have been the main focus for prevention on body image issues. Recently, research has found that males are experiencing increased rates of body dysmorphia and eating disorders [25]. Our study suggests that both males and females should be asked about dieting, eating, body image, and weight loss habits. The American Medical Association Guidelines for Adolescent Preventive Services (AMA GAPS) recommend that screening and counseling should occur annually for obesity and eating disorder and the American Academy of Pediatrics (AAP) recently recommended that annual BMIs should be recorded on growth charts for female and male adolescents to help predict and prevent overweight and obesity [17,26]. Although detection is important, the action taken after detection of a possible problem is equally vital. In one recent study, 25% of physicians reported not feeling competent to address obesity issues and 20% did not feel comfortable addressing obesity [27]. Screening is not being performed on a universal basis and barriers impeding screening need to be addressed. In one nationally representative survey many adolescents expressed a desire to discuss health risk factors with their healthcare providers, but relatively few had received any counseling [28]. In that survey 12.3% of adolescents reported ever binging and purging, but only 32% of them

608.e5

reported ever having discussed these issues with their provider. Similarly, 20.9% adolescents reported infrequent exercise (⬍2 times/week), but only 34.2% of them had ever discussed exercise issues [28]. The adolescents in our study had received care, and many reported having discussed nutrition issues. Although there is insufficient evidence for physician screening and counseling as an effective intervention for at-risk adolescents [29], the growing proportion of youth at risk have led the Institute of Medicine to recommend action based on the “best available” evidence as well as for future studies to address how brief interventions might best promote lifestyle changes and improve weight and activity outcomes [30]. Healthy People 2010 goals include reducing adolescent obesity from 11% to 5%, increasing physical activity and improving nutrition, and improving the accessibility of health information and services [31]. Other obesity programs targeting children and adolescents encourage preteens and teens to be physically active and improve the school nutrition environment by promoting fresh fruit distribution in school [31]. Additionally, limited programs promote positive body images in adolescents. For example, the Girl Power Body Wise program promotes awareness and knowledge concerning nutrition, fitness, and eating disorders [32]. Limitations The self-reported heights and weights used to classify adolescents into their BMI and “at risk” categories may influence the validity of our study. People tend to report lower weights and higher heights [33], which means the true proportion of “at risk” and overweight populations are likely higher than what was reported. In addition, factors not investigated in our study such as family structure, emotional state, and family history may also effect whether an adolescent is “at risk” for developing an eating disorder or being overweight [34]. We did not ask adolescents to weigh themselves, nor did we assess the likelihood of social desirability bias in underestimation. Recall of discussions may be biased by adolescents’ memory, or by systematic factors relating to weight, and these issues also were not assessed. We also did not separately assess whether discussions about weight between adolescents and other office staff (i.e., nurses) occurred. Also, although the study used 5th percentile in BMI as a cut-off for an eating disorder, there is no consensus among the field as to a certain weight or BMI to classify someone as “at risk” for an eating disorder. Anorexia nervosa usually means that the patient is unhealthily underweight, and therefore, likely to fall below that cut-off point. However, those with other eating disorders, such as bulimia nervosa, are usually normal or overweight, and therefore a BMI would not identify these patients. In addition, this study used the phrase “misclassification

608.e6

J.D. Klein et al. / Journal of Adolescent Health 38 (2006) 608.e1– 608.e6

of body image” instead of distorted body image. A distorted body image is usually used within the contexts of eating disorders and involves more psychological factors than simply classifying themselves into weight categories that do not accurately define their true BMI. Although many subjects who misclassified their BMI may also have a distorted BMI, it would be erroneous to make that assumption. Finally, sample and response bias needs to be considered. Our results may not be generalizable to other geographic areas, or to all populations, and adolescents who do not regularly see clinicians and those without telephones were not able to participate. Conclusion “At risk” adolescents are not receiving adequate diet and nutrition counseling. The large portion of adolescents who are “at risk” demonstrates the need for clinicians to screen and counsel adolescents about these issues. Discussion of body image issues, diet/weight loss, and nutrition should be part of all adolescent well visits. Acknowledgments This work was supported by a grant from the National Cancer Institute, “Primary Care and Self-Help Intervention for Teen Smokers” (Ossip-Klein, PI) RO1 CA80283 and by the Golisano Children’s Hospital at Strong, Strong Children’s Research Center and the Haggerty Friedman Psychosocial Fund. References [1] Yanovski JA, Yanovski SZ. Treatment of pediatric and adolescent obesity. JAMA 2003;289(14):1851–3. [2] Kreipe RE. Eating disorders among children and adolescents. Pediatr Rev 1995;16(10):370 –9. [3] Ogden CL, Flegel KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999 – 2000. JAMA 2002;288(4):1728 –32. [4] Aitman TJ. Genetics and obesity. N Engl J Med 2003;348(21): 2138 –9. [5] U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, MD: U.S. Department of Health and Human Services, Public Health Services Office of the Surgeon General: US GPO, Washington, DC, 2001. [6] Peeters A, Barendregt JJ, Willekens F, et al. Obesity in adulthood and its consequences for life expectancy: a life-table Aanalysis. Ann Intern Med 2003;138:24 –32. [7] Goodman E, Whitaker RC. A prospective study of the role of depression in the development and persistence of adolescent obesity. Pediatrics 2002;109:497–503. [8] Fairburn CG, Harrison PJ. Eating disorders. Lancet 2003;361:407–16. [9] Ricciardelli LA, McCabe MP. Sociocultural and individual influences on muscle gain and weight loss strategies among adolescent boys and girls. Psychol Sch 2003;40(2):209 –24. [10] Grignard S, Jean-Pierre B, Michel B, et al. Characteristics of adolescents’ attempts to manage overweight. Patient Educ Couns 2003;51:183–9.

[11] Sands R. Reconceptualization of body image and drive for thinness. Int J Eat Disord 1999;28:397– 407. [12] Tiggemann M, Gardiner M, Slater A. “I would rather be size 10 than have straight A’s”: a focus group study of adolescent girls’ wish to be thinner. J Adolesc 2000;23:645–59. [13] King N, Touyz S, Charles M. The effect of body dissatisfaction in women’s perceptions of female celebrities. Int J Eat Disord 2000; 27(3):341–7. [14] Gray DP. Dietary advice in British General Practice. Eur J Clin Nutr 1999;53(S2):S3– 8. [15] Lyznicki JM. Obesity: assessment and management in primary care. Am Fam Physician 2001;63(11):2185–96. [16] Centers for Disease Control and Prevention, National Center for Health Statistics. 2000 CDC growth charts: United States [cited 2003 Jun 4]. Available from: http://www.cdc.gov/growthcharts. [17] Elster AB, Kuznets NJ. Guidelines for Adolescent Preventive Services. Baltimore, MD: Williams and Wilkins, 1997. [18] Olsen LM, Inkelas M, Halfon N, et al. Overview of the content of health supervision for young children: reports from parents and pediatricians. Pediatrics 2004;104(6):1907–16. [19] Thompson SH, Rafiroiu AC, Sargent RG. Examining gender, racial, and age differences in weight concern among third, fifth, eighth, and eleventh graders. Eat Behav 2003;3:307–23. [20] Gustafson-Larson AM, Terry RD. Weight-related behaviors and concerns of fourth-grade children. J Am Diet Assoc 1992;92(7):818 –22. [21] McLean JA, Barr SI. Cognitive dietary restraint is associated with eating behaviors, lifestyle practices, personality characteristics and menstrual irregularity in college women. Appetite 2003;40:185–92. [22] Mehler PS. Diagnosis and care of patients with anorexia nervosa in primary care settings. Ann Intern Med 2001;134:1048 –59. [23] Halpern-Felsher BL, Ozer EM, Millstein SG, et al. Preventive services in a health maintenance organization. How well do pediatricians screen and educate adolescent patients? Arch Pediatr Adolesc Med 2000;154:173–9. [24] Boule CJ, McSherry JA. Patients with eating disorders. How well are family physicians managing them? Can Fam Physician 2002;48:1807–13. [25] Braun DL, Sunday SR, Huang A, Halmi KA. More males seek treatment for eating disorders. Int J Eat Disord 1999;25:415–24. [26] Krebs NF, Jacobson MS, American Academy of Pediatrics Committee on Nutrition. Prevention of pediatric overweight and obesity. Pediatrics 2003;112(2):424 –30. [27] Jelalian E, Boergers J, Alday CS, Frank R. Survey of physician attitudes and practices related to pediatric obesity. Clin Pediatr 2003; 42(3):235– 45. [28] Klein J, Wilson K. Delivering quality care: adolescents’ discussion of health risks with their providers. J Adolesc Med 1997;30:190 –5. [29] Cook S, Perrin E, Flower K, et al. Improving Health Services to Prevent Obesity in Children: Phase I. Presented at Robert Wood Johnson “Health Care Strategies for Addressing Childhood Obesity” meeting July 10, 2004, Washington, DC. [30] Institute of Medicine. Preventing childhood obesity [cited 2005 Feb 27]. Available from: www.nap.edu/books/0309091969/html/. [31] U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. Washington, DC: United States Department of Health and Human Services, Government Printing Office, 2000. [32] U.S. Department of Health and Human Services. Girl power [cited 2003 Sep 10]. Available from: http://www.girlpower.gov/girlarea/ bodywise/Index.htm. [33] Brener ND, McManus T, Galuska DA, et al. Reliability and validity of self-reported heights and weights among high school students. J Adolesc Health 2003;32:281–7. [34] Ricciardelli LA, McCabe MP, Bonfield S. Body image and body change methods in adolescent boys: role of parents, friends, and the media. J Psychosom Res 2000;49:189 –97.