[show abstract][hide abstract] ABSTRACT: To determine the prevalence of anemia from 4 to 26 weeks post partum and to examine prenatal predictors of postpartum anemia.
Retrospective cohort analysis of 59,428 participants in the Special Supplemental Nutrition Program for Women, Infants, and Children in 12 US states.
The prevalence of postpartum anemia was 27%. Anemia rates were higher among minority women, reaching 48% among non-Hispanic black women. Of 9129 women who had normal hemoglobin in the third trimester, 21% had postpartum anemia. Prenatal anemia was the strongest predictor of postpartum anemia (adjusted odds ratio, 2.7; 95% confidence interval, 2.5-2.8). Maternal obesity, multiple birth, and not breast-feeding also predicted postpartum anemia.
The high prevalence of post partum anemia among low-income women highlights the importance of anemia screening at 4 to 6 weeks post partum. These data suggest that screening should not be limited, as it is at present, to women considered at high risk.
American Journal of Obstetrics and Gynecology 09/2001; 185(2):438-43. · 3.88 Impact Factor
[show abstract][hide abstract] ABSTRACT: Population-based estimates of the prevalence of disease-associated mutations, such as hemochromatosis (HFE) gene mutations, are needed to determine the usefulness of genetic screening.
To estimate the prevalence of the HFE mutations C282Y and H63D in the US population.
Cross-sectional population-based study of samples in the DNA bank from phase 2 of the Third National Health and Nutrition Examination Survey conducted from 1992 to 1994.
Genotyped samples of cells from a total of 5171 participants, cross-classified by sex, age, and race/ethnicity in the analysis.
Estimates of the prevalence of C282Y and H63D mutations.
The prevalence of C282Y homozygosity is estimated to be 0.26% (95% confidence interval [CI], 0.12%-0.49%); 1.89% (95% CI, 1.48%-2.43%) for H63D homozygosity; and 1.97% (95% CI, 1.54%-2.49%) for compound heterozygosity. The prevalence estimates for C282Y heterozygosity (C282Y/wild type) are 9.54% among non-Hispanic whites, 2.33% among non-Hispanic blacks, and 2.75% among Mexican-Americans. The prevalence estimates of the C282Y mutation in the US population are 5.4% (95% CI, 4.7%-6.2%) and 13.5% (95% CI, 12.5%-14.8%) for the H63D mutation.
Estimates of prevalence of HFE mutations are within the expected range for non-Hispanic whites and blacks but the estimated prevalence of the C282Y mutation among Mexican-Americans is less than expected. Mutation data now need to be linked to clinically relevant indices, such as transferrin saturation level.
JAMA The Journal of the American Medical Association 06/2001; 285(17):2216-22. · 29.98 Impact Factor
[show abstract][hide abstract] ABSTRACT: Opinions expressed in commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees. Commentaries are not peer-reviewed.
[show abstract][hide abstract] ABSTRACT: To examine the association of maternal hemoglobin during pregnancy with preterm birth and small for gestational age (SGA).
We performed a retrospective cohort analysis of hemoglobin and birth outcome among 173,031 pregnant women who attended publicly funded health programs in ten states and delivered a liveborn infant at 26-42 weeks' gestation. We defined preterm as less than 37 weeks' gestation and SGA as less than the tenth percentile of a US fetal growth reference.
Risk of preterm birth was increased in women with low hemoglobin level in the first and second trimester. The odds ratio (OR) for preterm birth with moderate-to-severe anemia during the first trimester (more than three standard deviations [SD] below reference median hemoglobin, equivalent to less than 95 g/L at 12 weeks' gestation) was 1.68 (95% confidence interval [CI] 1.29, 2. 21). Anemia was not associated with SGA. High hemoglobin level during the first and second trimester was associated with SGA but not preterm birth. The ORs for SGA in women with very high hemoglobin level during the first and second trimester (more than three SDs above reference median hemoglobin, equivalent to greater than 149 g/L at 12 weeks' gestation and greater than 144 g/L at 18 weeks') were 1.27 (95% CI 1.02, 1.58) and 1.79 (95% CI 1.49, 2.15), respectively.
These data highlight the importance of considering anemia and high hemoglobin level as indicators for adverse pregnancy outcome. An elevated hemoglobin level (greater than 144 g/L) is an indicator for possible pregnancy complications associated with poor plasma volume expansion, and should not be mistaken for good iron status.
[show abstract][hide abstract] ABSTRACT: To examine associations between rate of pregnancy weight gain and preterm delivery among women of varying prepregnancy body mass indices (BMI).
Subjects were 3511 mother-infant pairs from the 1988 National Maternal and Infant Health Survey. Prenatal weight measured between 14 and 28 weeks' gestation was used to calculate rate of pregnancy weight gain for each woman. Weight gain (lb/week) was categorized as low (under 0.5), average (0.5-1.5), or high (above 1.5). Prepregnancy BMI was calculated as weight divided by height in (kg/m(2)) and categorized as low (under 19.8), average (19.8-26.0), and high (above 26). Delivery before 37 weeks' gestation was considered preterm. Associations between BMI, weight gain, and preterm delivery were examined before and after exclusion of medically indicated preterm deliveries and pregnancies complicated by maternal medical conditions potentially related to weight gain or fetal growth restriction. Associations were expressed as odds ratios (OR) adjusted for several potential confounding factors.
Women with low pregnancy weight gain were at increased risk of preterm delivery. The magnitude of risk varied according to a woman's prepregnancy BMI. After all exclusions and adjustments for confounders, ORs, and 95% confidence intervals (CI) for low pregnancy weight gain were 6.7 (1.1, 40.6) for underweight women, 3.6 (1.6, 8.0) for average-weight women, and 1.6 (0.7, 3.5) for overweight women compared with average-weight women with average pregnancy weight gain.
Low weight gain in pregnancy was associated with increased risk of preterm delivery, particularly if women were underweight or of average weight before pregnancy.
Obstetrics and Gynecology 09/2000; 96(2):194-200. · 4.80 Impact Factor
[show abstract][hide abstract] ABSTRACT: We examined the association between serum ferritin concentration and the risk of diabetes.
We examined the cross-sectional associations among ferritin concentration, glucose tolerance status, and concentrations of insulin, glucose, and glycosylated hemoglobin in 9,486 U.S. adults aged > or = 20 years from the Third National Health and Nutrition Examination Survey (1988-1994).
After adjusting for age, sex, ethnicity, education, BMI, alcohol consumption, alanine aminotransferase concentration, C-reactive protein concentration, and examination session attended, and after dichotomizing ferritin concentration into < 300 and > or = 300 micrograms/l for men and < 150 and > or = 150 micrograms/l for women, the odds ratios for newly diagnosed diabetes were 4.94 (95% CI 3.05-8.01) for men and 3.61 (2.01-6.48) for women. The increased risk of newly diagnosed diabetes was concentrated among participants with transferrin saturations < 45%. All multiple linear regression coefficients between ferritin concentration and concentrations of insulin, glucose, and glycosylated hemoglobin were positive and significant for both men and women.
Elevated serum ferritin concentration was associated with an increased risk of diabetes. We were unable to eliminate conclusively the possibility that the observed association reflected inflammation rather than excess body iron stores.
Diabetes Care 01/2000; 22(12):1978-83. · 7.74 Impact Factor
[show abstract][hide abstract] ABSTRACT: This study examined the validity of self-reported delivery weight among 3,518 respondents to the 1988 National Maternal and Infant Health Survey. Self-reported delivery weight was ascertained from a mail survey administered during the postpartum period. Measured delivery weight was obtained by abstraction of medical records from the hospital of delivery. On average, a woman's reported delivery weight was 2.82 pounds (1 pound = 0.45 kg) less than her measured delivery weight (p < 0.001). The level of underreporting increased significantly with increases in prepregnancy body mass index, current body mass index, pregnancy weight gain, and weight change from delivery to recall. Reporting error also increased among women who were non-White, less educated, and unmarried; whose pregnancy was unintended; and who initiated prenatal care late, responded late to the survey questionnaire, became pregnant again before responding, and reported a delivery weight ending in zero. When reported delivery weight was used to calculate weight gain and was categorized into typical weight gain categories, 30-40% of women were classified incorrectly. An empirical evaluation of how this misclassification might impact epidemiologic analyses indicated that associations between weight gain and birth weight were attenuated when weight gain was based on reported delivery weight rather than on measured delivery weight.
American Journal of Epidemiology 11/1999; 150(9):947-56. · 4.78 Impact Factor
[show abstract][hide abstract] ABSTRACT: To evaluate whether advice on pregnancy weight gain from health care professionals, women's target weight gain (how much weight women thought they should gain), and actual weight gain corresponded with the 1990 Institute of Medicine recommendations.
Predominantly white, middle-class women participating in a mail panel reported their prepregnancy weights, heights, and advised and target weight gains on a prenatal questionnaire (n = 2237), and their actual weight gains on a neonatal questionnaire (n = 1661). Recommended weight gains were categorized for women with low body mass index (BMI) (less than 19.8 kg/m2) as 25-39 lb; for women with average BMI (19.8-26.0 kg/m2) as 25-34 lb; and for women with high BMI (more than 26.0-29.0 kg/m2) and very high BMI (more than 29.0 kg/m2) as 15-24 lb.
Twenty-seven percent of the women reported that they had received no medical advice about pregnancy weight gain. Among those who received advice, 14% (95% confidence interval [CI] 12%, 16%) had been advised to gain less than the recommended range and 22% (95% CI 20%, 24%) had been advised to gain more than recommended. The odds of being advised to gain more than recommended were higher among women with high BMIs and with very high BMIs compared with women with average BMIs. Black women were more likely than white women to report advice to gain less than recommended. Advised and target weight gains were associated strongly with actual weight gain. Receiving no advice was associated with weight gain outside the recommendations.
Greater efforts are required to improve medical advice about weight gain during pregnancy.
Obstetrics and Gynecology 11/1999; 94(4):616-22. · 4.80 Impact Factor
[show abstract][hide abstract] ABSTRACT: Hemochromatosis reportedly affects 3 to 8 persons per 1,000 and is associated with an elevated risk of morbidity and mortality. We sought to ascertain its prevalence in a community and to assess the association between phenotype and genotype.
All health maintenance organization employees were invited to participate in hemochromatosis screening using a repeated elevation of the transferrin saturation test as the case definition (> or = 50% in women and > or = 60% in men with no other cause). Iron overload from hemochromatosis was defined as serum ferritin concentration > or = 95th percentile and mobilizable iron > or = 99th percentile for age and sex, or hepatic iron index > or = 1.9. The HFE gene was analyzed for mutations.
Participation among employees was 28% (1,653 of 6,000); 83% were women. The prevalence of hemochromatosis was 8 per 1,000 (13 of 1,653), and the prevalence of iron overload from hemochromatosis was 4 per 1,000 (5 of 1,653). Compared with those who had no HFE mutation, the relative risk (RR) for hemochromatosis was greatest for C282Y homozygotes (RR = 147), compound heterozygotes (RR = 19), and H63D homozygotes (RR = 9). Overall, 38% of participants had at least one HFE mutation. Screening based on an initial elevated transferrin saturation test had the best sensitivity, whereas DNA testing offered the best specificity and predictive value positive for iron overload disease.
In this population, we found a greater than expected prevalence of hemochromatosis and demonstrated a clear association with the HFE genotype. Promotion of screening is complicated by controversies in case definition and the large number of persons who will be detected before they have clinically significant iron loading, in whom the risk of clinical disease is unknown. Larger screening studies in more diverse populations are necessary to characterize the burden of disease and to follow those at risk (based on HFE or iron status measures) to establish the natural history of hemochromatosis.
The American Journal of Medicine 07/1999; 107(1):30-7. · 4.77 Impact Factor
[show abstract][hide abstract] ABSTRACT: We examined associations between weight gain (kg) per week of pregnancy and net weight gain per week of pregnancy (weight gain - birth weight/weeks of gestation at delivery) and preterm delivery in a population of 266,172 low-income women. Risk of preterm delivery was lowest among women with intermediate weight gain (0.35 to <0.46 kg/week) and net weight gain (0.27 to <0.37 kg/week). Both lower and higher weight gains and net weight gains per week were associated with an increased risk for preterm delivery. Associations, however, were not uniform across body mass index categories. Compared with women gaining 0.35 to <0.46 kg/week, preterm risk differences (95% confidence limits) for women gaining <0.10 kg/week were +9.5% (+6.5, +12.4) for underweight women, +6.7% (+5.6, +7.9) for average-weight women, +3.5% (+2.0, +4.9) for overweight women, and +0.4% (-0.4, +1.2) for obese women. The opposite pattern was observed with high weight gain. Preterm risk differences for weight gains >0.65 kg/week ranged from +0.8% (-0.7, +2.1) for underweight women, to +2.5% (+1.3, +3.9) for obese women. We also evaluated weight gain per week in the latter part of pregnancy (from week 14 to delivery). The same basic patterns were observed; however, variation in the associations across body mass index groups was not as marked.
[show abstract][hide abstract] ABSTRACT: The discovery of the HFE gene in 1996 has introduced DNA testing as a possible tool for screening and diagnosis of hemochromatosis and increased interest in the disorder. Population screening using transferrin saturation has been advocated by experts to permit early detection and treatment with phlebotomy before the onset of clinical disease.
Based on a literature review, we consider the relative risks and merits of two screening tests as part of a broader look at the evidence required for the recommendation of universal screening for hemochromatosis.
Several questions must be answered before universal screening can be recommended. Uncertainties remain about the penetrance and preventable disease burden, laboratory standardization, and optimal strategies to minimize potential risks of screening for hemochromatosis.
As a common genetic disorder with simple, effective therapy, hemochromatosis offers a model for other genetically influenced chronic diseases that some day may have interventions to improve prognosis. Resolution of questions related to prevention of chronic diseases from hemochromatosis, therefore, will have broad usefulness in the future.
American Journal of Preventive Medicine 03/1999; 16(2):134-40. · 3.95 Impact Factor
[show abstract][hide abstract] ABSTRACT: Population screening for hemochromatosis done by using the transferrin saturation test has been advocated by experts to permit the initiation of therapeutic phlebotomy before the onset of clinical disease. The discovery of a gene associated with hemochromatosis has made DNA testing another option for screening and diagnosis. In this paper, U.S. Preventive Services Task Force criteria are used to evaluate the evidence for the usefulness of population screening done by using iron measures or genetic testing. Published clinical research offers little evidence to suggest that population screening for hemochromatosis done by using genetic testing improves clinical outcomes. Although one recently discovered mutation, C282Y, accounts for 60% to 92% of cases of the disease in series of patients with hemochromatosis, uncertainties remain about the clinical penetrance of various genotypes; the accuracy of genetic testing; and the ethical, legal, and social effects of genetic testing. Before population screening for hemochromatosis done by using transferrin saturation testing can be recommended, laboratory standardization needs to be addressed and questions about risk for clinical disease in asymptomatic persons with mutations or early biochemical expression of disease require resolution. Evidence from case series suggests that hemochromatosis may be associated with liver cancer, other liver disease, diabetes, bradyarrhythmias, and arthritis. In all studies but one, however, estimation of the magnitude and significance of this risk is limited by lack of adequate comparison groups. The need for population data to answer questions about penetrance among asymptomatic persons should not impede efforts to increase the detection and treatment of hemochromatosis in persons found to have elevated iron measures a family history of hemochromatosis, or consistent early signs and symptoms of the disease.
Annals of internal medicine 01/1999; 129(11):971-9. · 13.98 Impact Factor
[show abstract][hide abstract] ABSTRACT: As part of the Iron Overload, Public Health and Genetics conference, sponsored by the Centers for Disease Control and Prevention in March 1997, a working group was convened to consider strategies to increase early case detection of hemochromatosis. This group emphasized that the primary public health goal should be to diagnose hemochromatosis before symptoms appear. To reach this goal, education and action need to be targeted to physicians and other health care workers, laboratorians, administrators, payers, and the public. Strategies to disseminate updated information and increase early case detection were prioritized according to expected effectiveness. Strategies targeting physicians are 1) to identify national and local physician-leaders and 2) to educate physicians about hemochromatosis in basic, graduate specialty, and continuing medical education. Strategies aimed at the health system are 1) to encourage laboratories to provide the transferrin saturation test as part of routine laboratory panels and 2) to work with policymakers and payers to allow reimbursement for case detection. Finally, public education is recommended to increase lay support for the early diagnosis of hemochromatosis. Attempts to educate the public should be aimed first at persons who receive diagnoses of hemochromatosis in order to ensure that they are properly treated and then at asymptomatic persons who could be screened as part of health appraisals. Although identifying physician-leaders and educating physicians are the highest priorities, physicians should not be targeted at the exclusion of payers and the public. Simultaneous efforts to reach all groups in appropriate ways should be initiated to provide the interest and infrastructure necessary to decrease morbidity and mortality from hemochromatosis.
Annals of internal medicine 01/1999; 129(11):987-92. · 13.98 Impact Factor
[show abstract][hide abstract] ABSTRACT: The recent realization that hemochromatosis is a common condition has created opportunities to develop unified public health surveillance for this disorder and its complications and to design programs to prevent unnecessary illness and death resulting from this disorder. Public health surveillance for hemochromatosis can be used to measure the magnitude of the problem (for example, to establish the number of persons with evidence of early iron overload); identify research needs; reveal the natural history of the disease; detect changes in health care practices, such as use of screening tests; and evaluate interventions, such as phlebotomy. Existing surveillance has been limited to periodic measurement of morbidity and mortality done by using hospital discharge records, health examination surveys, vital statistics, and data from small research registries. The improvement of surveillance will entail the ongoing collection of information from population-based surveys, such as the Behavioral Risk Factor Surveillance System; the collection of data on provider practices (for example, through the National Ambulatory Medical Care Survey); and the establishment of population-based registries. Creating population-based registries requires consensus on case definitions; strategies to encourage case ascertainment and reporting; policies and procedures for protecting privacy and ensuring confidentiality; and partnerships among providers, researchers, and public health officials. Longitudinal data from population-based registries will provide insight into determinants of disease expression, such as pattern or degree of iron overload. This information is critical for developing evidence-based recommendations for population screening, monitoring changes in medical practices, and assessing the effect of preventive measures.
Annals of internal medicine 01/1999; 129(11):980-6. · 13.98 Impact Factor
[show abstract][hide abstract] ABSTRACT: To examine associations between pregnancy weight gain outside and within ranges recommended by the Institute of Medicine and birth weight by both prepregnant body mass index (BMI) and race-ethnicity.
Mean birth weight and incidence of term low birth weight (LBW, less than 2500 g) and high birth weight (more than 4500 g) were compared across BMI-pregnancy weight gain-race-ethnicity strata. Subjects were 173,066 white, black, and Hispanic low-income pregnant women attending prenatal nutrition programs between 1990 and 1993.
Among low and average BMI women (all race-ethnicity groups), weight gain within Institute of Medicine ranges resulted in significant LBW reductions; further LBW reductions at gains beyond Institute of Medicine ranges were offset by increasing high birth weight risk. Among women of high and obese BMI, LBW trends were less pronounced; thus, the benefit of gaining within the Institute of Medicine range was less apparent. Although blacks in every BMI-weight gain category had lower mean birth weights than white women, gaining in the upper end of the Institute of Medicine ranges did not provide a consistent LBW reduction for black women; adjusted LBW odds ratios and 95% confidence intervals for gains in the upper relative to the lower half of the Institute of Medicine range were 1.3 (0.8, 2.1), 0.7 (0.5, 1.03), 0.3 (0.2, 0.8), and 1.3 (0.7, 2.5) for black women of low, average, high, and obese BMI, respectively.
Institute of Medicine pregnancy weight gain ranges recommended for low and average BMI women appear reasonable, but recommendations for high and obese BMI women require further evaluation. The recommendation that black women in all BMI groups strive for gains toward the upper ends of the ranges is not supported clearly by these data.
Obstetrics and Gynecology 07/1998; 91(6):878-84. · 4.80 Impact Factor
[show abstract][hide abstract] ABSTRACT: To examine the proportion of women with a pregnancy weight gain below, within, and above ranges recommended by the Institute of Medicine from 1990 to 1996.
Our study population included women attending Special Supplemental Nutrition Program for Women, Infants and Children (WIC) clinics in five states who delivered a liveborn singleton infant at term (N = 120,531). Pregnancy weight gain was self-reported at the postpartum visit.
Only 34% of women gained weight within recommended ranges and there was little change in this proportion from 1990 to 1996. The proportion of women gaining less than their recommended weight decreased from 23.4% to 22.0%, and the proportion gaining more than recommended increased from 41.5% to 43.7% during the study period. Stratified analyses revealed similar trends within all race-ethnicity, age, parity, trimester of WIC initiation, and trimester of prenatal care initiation strata and among women in low, average, and high prepregnancy body mass index categories. There was no change in the weight gain distribution among obese women. Absolute and relative increases in the proportion of women gaining more weight than recommended were greatest among women who were underweight, Asian or Native American, less than 20 years of age, multiparous, and who initiated WIC and prenatal care in the third trimester.
Pregnancy weight gain increased among this population of WIC participants from 1990 to 1996.
Maternal and Child Health Journal 07/1998; 2(2):111-6. · 2.24 Impact Factor
[show abstract][hide abstract] ABSTRACT: We compare prevalence estimates of self-perceived health status and chronic disease risk factors from a managed care member survey with estimates from the Behavioral Risk Factor Surveillance System (BRFSS) survey. Unadjusted prevalence estimates for diabetes, high blood pressure, and current smoking status were similar in the two surveys. In contrast, 5.1 percent of respondents to the managed care member survey reported fair-to-poor health status, compared with 12.4 percent of respondents to the BRFSS survey. Standardization of demographic characteristics reduced the prevalence of reported fair-to-poor health status among BRFSS respondents to 9 percent. We conclude that standardized survey questions added to annual member surveys in managed care organizations are a feasible and potentially useful method of chronic disease surveillance.
Health Affairs 01/1997; 16(6):219-27. · 4.64 Impact Factor
[show abstract][hide abstract] ABSTRACT: We conducted a telephone survey of female managed care enrollees who recently had a normal vaginal delivery to examine the relationship between hospital length-of-stay and maternal characteristics, pregnancy factors, length-of-stay preferences, and postdischarge experiences. Results indicated that length-of-stay varied by maternal characteristics and pregnancy factors. Length-of-stay and maternal or newborn readmissions were not statistically associated. Most respondents reported that they would be willing to go home within twenty-four hours after future deliveries if additional services were provided. Emphasis should be placed on which services can be provided to prepare and assist mothers through the perinatal period.
Health Affairs 01/1997; 16(3):198-208. · 4.64 Impact Factor
[show abstract][hide abstract] ABSTRACT: To examine the relationship between characteristics of obstetrician-gynecologists and rates of recommended prenatal care screening tests.
Retrospective review of prenatal care records.
Enrolled women (2184) between 14 to 47 years of age who delivered a live birth in 1992, and saw an obstetrics and gynecology (OB/GYN) physician for prenatal care.
Receipt of routine prenatal care screening tests.
Pregnant women received most of the recommended prenatal care screening tests more than 90% of the time, with the exception of urinalysis (68.3%), alphafetoprotein (72.1%), glucose challenge (87.5%), and repeat haemoglobin/hematocrit (71.0%). Rates of receiving recommended screening tests varied by obstetrician's gender and number of years since medical school graduation. Women were more likely to receive an antibody test if they saw a female rather than a male obstetrician (p < 0.05), and more likely to receive syphilis serology, rubella, glucose challenge and repeat hemoglobin and/or hematocrit tests if they saw an obstetrician who graduated from medical school within the past 30 years (1965 or later), rather than an obstetrician who graduated more than 30 years ago (p < 0.05).
The receipt of prenatal care screening tests varies by characteristics of OB/GYN physicians. The results of this study suggest that targeting educational opportunities to OB/GYN physicians whose year of medical school graduation is 1965 or earlier may improve rates of recommended prenatal screening tests.
[show abstract][hide abstract] ABSTRACT: To assess the prevalence and correlates of weight loss during pregnancy.
Cross-sectional telephone survey from 47 states and the District of Columbia.
1794 women who reported that they were pregnant at the time of the survey.
Self-reported weight, height, disease and behaviors.
A minority (3.7%; 95% CI, 2.6-4.9%) of women who reported being pregnant (n = 1794) also reported trying to lose weight. However, pregnant women who reported both drinking alcohol in the past month and currently smoking had the highest prevalence of attempted weight loss (12.7%), followed by women in their first trimester (9.4%), women with reported diabetes (9.0%) and women with very high BMIs (6.9%). After adjustment for survey design and other characteristics, women in their first trimester were four times more likely to attempt weight loss than those in the third trimester.
These results suggest that weight loss attempts among women who report being pregnant are uncommon, but are more likely to occur in the first trimester and possibly among women who smoke and drink, have diabetes or are very overweight.
International Journal of Obesity 05/1996; 20(4):373-5. · 5.22 Impact Factor