Dietary Calcium Intake in Lactose Maldigesting
Intolerant and Tolerant African-American Women
Maciej S. Buchowski PhD, Joyce Semenya, MD, and Abiodun O. Johnson, MD, FACN
Center for Nutrition (M.S.B., A.O.J.) and Department of Family and Community Medicine (M.S.B., J.S.) at Meharry Medical
College, 1005 D.B. Todd Blvd., Nashville, Tennessee
Key words: dietary calcium, lactose maldigestion, lactose tolerance, African-American women, body mass index
Background: The relationship between lactose maldigestion, lactose intolerance, and calcium intake in
premenopausal African American women is unknown.
Objective: To determine how intolerance of lactose and dairy products affects intake of calcium in lactose
maldigesting premenopausal African American women.
Design: Dietary intake of calcium was assessed in 50 premenopausal lactose maldigesting African American
women as determined by the breath hydrogen test. Twenty-six women were lactose intolerant and 24 were
lactose tolerant by self-reports.
Results: The average intake of calcium in lactose maldigesting and intolerant women was significantly lower
than in lactose tolerant women (388 ? 150 mg/day vs. 763 ? 333 mg/day, p ? 0.0001, t test). Neither group
reached the newly established Dietary Reference Intake (DRI) for calcium (1,000 mg/day). Major source of
dietary calcium in lactose tolerant women were milk and dairy products (45%), and mixed foods containing
calcium from non-dairy sources (30%). In lactose intolerant women, 46% of calcium was from mixed foods and
only 12% was from milk and dairy products. Lactose intolerant women had higher body mass index (BMI) than
lactose tolerant women (p ? 0.008, t test), and calcium intake was negatively associated with BMI (R2? 0.470).
Conclusions: In African American premenopausal women, lactose tolerance facilitates the dietary intake of
calcium when compared with their lactose intolerant counterparts. Low calcium intake is associated with higher
Lactase insufficiency and consequent lactose maldigestion
occurs in a majority of the various ethnic minorities in the U.S.
It is particularly common among African-Americans in whom
prevalence rate is 70% to 75% . Present at birth, the ability
to digest lactose is decreased to ?10% of childhood levels in
human adult-onset lactase (lactase-phlorizin hydrolase—LPH)
decline [2, 3]. This decline demonstrates an autosomal reces-
sive pattern of inheritance  and is regulated primarily by the
rate of lactase gene transcription [5–7], although the molecular
mechanism that regulates the decline is currently unknown .
Nevertheless, lactase-insufficient individuals malabsorb lactose
but may or may not show intolerance symptoms [9–11]. In-
gestion of high quantities of lactose-containing foods such as
milk and dairy products by individuals with adult-onset lactase
decline can result in gastrointestinal symptoms such as abdom-
inal pain, bloating, flatus and diarrhea . The development
of symptoms appears to depend on the dose of lactose ingested,
whether ingestion is part of a meal or is accompanied by
ingestion of a meal or other food, rate of gastric emptying and
small intestine transit time . Nevertheless, lactose intoler-
ance due to lactose insufficiency usually leads to self-imposed
dietary restriction by the individual of milk and dairy products,
which are the major source of dietary calcium in the U.S. .
With the relatively low rate of milk and dairy foods intake
among minority groups especially African Americans, there is
a concern that calcium intake is low in this group. A recent
National Institutes of Health Consensus Conference concluded
that calcium intake of 1,000–1,500 mg/day may prevent, and
Address reprint requests to: Maciej S. Buchowski, PhD, Center for Nutrition, Meharry Medical College, 1005 D.B. Todd Blvd., Nashville, TN 37208. E-mail:
Present address for Abiodun O. Johnson, MD: Division of Gastroenterology & Nutrition, Texas Tech University Health Sciences Center, Amarillo, TX
Journal of the American College of Nutrition, Vol. 21, No. 1, 47–54 (2002)
Published by the American College of Nutrition
1,500 mg per day may reduce the incidence and severity of
postmenopausal osteoporosis . Consequently, the Food and
Nutrition Board of the National Research Council set a Dietary
Reference Intake (DRI) for calcium in premenopausal women
(21 to 50 years of age) at 1,000 mg per day . Implemen-
tation of this recommendation requires a diet that is naturally
rich in calcium such as milk and dairy products or ingestion of
calcium supplements and calcium-fortified foods. Milk and
dairy products, however, contain substantial quantities of lac-
tose, and gastrointestinal symptoms caused by lactose maldi-
gestion lead to avoidance of dairy foods. Previously, we have
shown that African Americans who are lactose maldigesters
can adopt and tolerate well a meal containing lactose .
Other workers have reported that lactose maldigesters could
tolerate diet containing milk and diary product with a substan-
tial amount of lactose and up to 1,500 mg of calcium [13, 18].
Nevertheless, there is considerable variability in the pattern of
dairy products consumption among lactose maldigesters [19–
21] who may have lower intakes of calcium. Indeed, some
reports have shown lower calcium intake in lactose maldigest-
ers when compared to lactose digesters and tolerant individuals
Recently, several clinical studies of dietary calcium have
shown a negative association between calcium intake and body
weight. For example, in a double-blind, placebo-controlled,
randomized trial of calcium supplementation, the calcium-sup-
plemented subjects exhibited a significant weight loss across
nearly four years of observation . Estimation of the rela-
tionship between calcium and body weight indicated that a
1,000-mg Ca intake difference was associated with an 8-kg
difference in mean body weight . Moreover, population
based data from NHANES III supported this notion showing a
profound reduction in the odds of being in the highest quartile
of adiposity with the increase in calcium and dairy product
intake . Recently, Lin et al.  have reported that young
women with high calcium intake, corrected by total energy
intake, and lower vitamin A intake gained less weight and body
fat in a two-year randomized exercise trial. Similar association
between calcium intake and body weight has been shown in
children [27–28]. In their longitudinal study, Carruth and Skin-
ner  showed that higher intakes of calcium, monounsatu-
rated fat and dairy products were associated with lower body
fat. Tanesescu et al.  have reported that among other
factors, such as TV viewing, frequency of fruit juice consump-
tion and maternal BMI, lower intake of dairy products was
associated with obesity in Puerto Rican children.
The goal of this study was to determine how perceived
intolerance of lactose affects intake of calcium in premeno-
pausal African American women who are lactose maldigesters.
The null hypothesis was that there is no significant difference
in daily calcium intake between lactose and dairy products
tolerant and intolerant groups of lactose maldigesters. A sec-
ondary objective of this study was to examine the association,
if any, between calcium intake and body mass in African
American women lactose maldigesters.
SUBJECTS AND METHODS
Fifty-seven African American women who volunteered and
gave an informed consent participated in this study. The pro-
tocol was approved by the Meharry Medical College Institu-
tional Review Board Committee on Human Investigations. By
design, all participating subjects were selected from a group of
83 initially screened women who had been classified as lactase
deficient on the basis of a rise in breath hydrogen concentration
of greater than 0.90 ?mol/L (?20 ppm) after ingestion of 25 g
of lactose in 250 mL of water. Briefly, lactose absorption was
assessed by measuring alveolar breath hydrogen exhalation at
15 minute intervals for three hours following an oral challenge,
as we described previously . All women were premeno-
pausal as assessed by self-reported frequency of menstruation
in the preceding three-month period.
Reporting of Symptoms
The occurrence and severity of symptoms were self-rated by
the subjects after ingesting 250 mL of lactose containing or
lactose-free milk as described by Suarez et al. . Subjects
reported occurrence and severity of abdominal fullness or
cramps, flatulence, borborygmi and diarrhea on a 0-to-5 scale
as follows: 0 ? no symptoms, 1 ? trivial, 2 ? mild, 3 ?
moderate, 4 ? strong and 5 ? severe. Women with scores of at
least 3 on this scale after ingesting lactose-containing milk
were classified as lactose intolerant (LI group). Women who
scored 2 or less after drinking lactose containing milk were
classified as lactose tolerant (LT group). Before the present
study, all 26 women who were lactose intolerant and four
women who self-reported lactose tolerance believed that inges-
tion of milk and dairy products caused them to have gastroin-
testinal discomfort. Seven women were excluded from final
analyses; two withdrew from the study, and five women did not
complete dietary records.
Each participant kept a seven-day dietary record (Monday–
Sunday) starting 7 to 12 days after the lactose challenge. A
dietitian met with each participant and explained proper record
keeping and the amount of food eaten was quantified in grams,
cups, ounces, teaspoons, tablespoons, pieces, slices, etc. as
necessary for analysis. In addition, each participant received a
small kitchen balance, standardized report forms and National
Dairy Council food models to help in assessing portion size. All
subjects did dietary recording during the same season (early
summer) to minimize measurement bias related to seasonal
Lactose Intolerance and Calcium Intake
48VOL. 21, NO. 1
availability of foods. All foods eaten, including snacks and
drinks, were recorded over a seven-day period. Use of dietary
supplements, including calcium supplements, was not encour-
aged or discouraged and intakes were reported. After comple-
tion, all records were collected and initially screened by a
dietitian. Any problems with identification of foods, methods
of preparation and portion sizes were discussed with subjects
over the telephone. Dietary intakes were analyzed using Food
Processor (Version 7.0, ESHA Research, Salem, OR).
Data are mean ? SD. Continuous variables between sub-
jects were evaluated using independent sample t tests. The
significance of differences in dietary calcium intake was ana-
lyzed using one-way ANOVA. Multiple linear regression anal-
ysis was performed on calcium intake (mg/day) and calcium
intake corrected for energy intake (mg Ca/1,000 kcal/day) by
use of a forward elimination approach. Covariates that were
considered for inclusion were lactose tolerance (0 ? lactose
intolerant, 1 ? lactose tolerant), BMI, age and plausible inter-
actions among these. Age was treated as a continuous variable.
Analyses were performed using SPSS-PC (Version 10) soft-
ware package. A p value of ? 0.05 was used for inclusion of
terms in the regression and to indicate statistical significance. A
sample size was chosen based on the variability of calcium
intake observed in our pilot studies with African American
women and NHANES III reports .
Table 1 presents descriptive data for study participants.
Hydrogen excretion after a lactose tolerance test was similar in
the LT and LI groups (p ? 0.567) and confirmed lactose-
maldigestion in all participating women. Women in the LI
group were heavier and had higher mean BMI than women in
the LT group (p ? 0.05 for both parameters).
Energy, Macronutrient, and Selected Micronutrient
The difference in average daily energy intake between LI
(128 ? 17.4 kJ/kg BW; 30.1 ? 4.15 kcal) and LT (115 ? 25.2
kJ/kg BW; 27.5 ? 6.02 kcal) groups was not significant (p ?
0.084, t test). Total average daily energy intake was 10,343 ?
1,691 kJ (2,470 kcal) in the LI group and 7,991 ? 1,504 kJ
(1,910 kcal) in the LT group, and the difference was significant
(p ? 0.001, ANOVA). Average difference in energy intake
calculated per kg of body weight (BW) between LI and LT was
not significant. Average macronutrient energy distributions
from protein, fat, and carbohydrates, were 18.9 ? 5.1% vs.
15.6 ? 4.6, 41.4 ? 7.4% vs. 34.2 ? 9.1, and 39.7 ? 10.9% vs.
50.1 ? 12.9 in LI and LT groups respectively. Intakes of
sodium and vitamin were similar in both groups (Table 2).
As presented in Table 2, the average daily Ca intake was
significantly higher in LT than LI women (780 ? 305 vs.
388 ? 151 mg/day, p ? 0.001, t test). Neither group reached
the recommended Dietary Reference Intakes of 1,000 mg of
calcium daily. In the LT group, five women (21%) had higher
intake of calcium than current recommendations while in the LI
group, only one woman reported intake of calcium supplement
that reached recommended calcium intake level. Calcium den-
sity (calcium intake divided by energy intake) was also signif-
icantly lower in LI than in LT group (166 ? 71 mg Ca vs.
420 ? 166 mg Ca per 1,000 kcal (4,184 kJ); p ? 0.001,
ANOVA). Major sources of calcium in the LT group were milk
and yogurt (22 ? 18%), and dairy products (24 ? 17%). In LI
women, mixed foods were a major source of calcium (46 ?
6%). This food group include breads, noodles, salad dressings,
meat and meat products, eggs and eggs products. Since calcium
supplements use was reported only once by four women in LT
and one woman in LI group, it was included in the mixed foods
group. Vegetables and fruits provided 9 ? 4% and 12 ? 6% of
calcium in LI and LT women, respectively. These results are
presented in Fig. 1.
Calcium Intake and Body Weight
A multiple regression analysis (Table 3) showed a negative
linear association between calcium intake and BMI, which was
an important predictor of calcium intake (p ? 0.001). The
overall regression equation was Calcium intake (mg per day) ?
913.1 ? 17.48 * BMI (kg/m2) ? 315.4 * Lactose Tolerance;
(R2? 0.470). A similar association was observed when cal-
cium intake was expressed as density (mg Ca/1000 kcal/day).
The overall regression equation was Calcium density (mg/
1,000 kcal/day) ? 505.2 ? 11.47 * BMI (kg/m2) ? 208.5 *
Lactose Tolerance; (R2? 0.605). These results are presented in
Table 1. Subject Characteristics
(n ? 26)
(n ? 24)
Hydrogen excretion (ppm)
Symptoms response to milk test
34.1 ? 6.8
80.9 ? 12.4*
165 ? 3.8
29.6 ? 4.7*
48.1 ? 8.8
37.1 ? 6.6
69.7 ? 15.1
165 ? 4.4
25.6 ? 5.4
44.1 ? 9.7
3.8 ? 1.4*1.3 ? 1.2
* Significantly different from Lactose Tolerant (LT) group (p ? 0.001, t test).
Lactose Intolerance and Calcium Intake
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION49
A major finding of this study is that African American
premenopausal women who are lactose maldigesters and
showed lactose intolerance to a single 25 g dose of lactose have
lower calcium intake than maldigesters who are milk and dairy
products tolerant. Moreover, lactose intolerant women with
lower intake of calcium had higher BMI than lactose tolerant
women who had higher intakes of calcium.
It is commonly believed that the symptoms resulting from
lactose maldigestion limit the amount of lactose and dairy rich
foods ingested by lactose maldigesters . In the present
study, lactose intolerant women had lower intake of milk and
dairy products than age-matched lactose tolerant women. It is
probable that the gastrointestinal discomfort associated with
reduced lactose tolerance contributed to the decline in milk
consumption in lactose intolerant women. We  and others
[11, 30–32] in double-blind studies have shown that persons
with lactose maldigestion experience negligible symptoms
when they ingest up to two cups of milk. Nevertheless, the
anticipation of symptoms resulting from lactose maldigestion
leads many lactose intolerant individuals to shun consumption
of milk and selected dairy products.
Questions have been raised about the adequacy of dietary
calcium intake in populations with a high prevalence of lactose
maldigestion and lactose intolerance. For example, Mainguet et
al.  evaluated the calcium intake of 134 patients with
abdominal symptoms after consumption of dairy products.
They found that the daily calcium intake of patients lacking
lactose activity in the jejunal biopsy was significantly lower
than that of controls. However, in patients with partial lactase
deficiency, calcium intake did not differ from that of controls.
Table 2. Daily Intake of Energy, Protein, and Calcium in Lactose Maldigesters African American Women According to Self-
reported tolerance of Milk and Dairy Products
Lactose Intolerant (n ? 26) Lactose Tolerant (n ? 24)
(n ? 1479)
% of DRI
% of DRI
Vitamin D (?g/day)
10343 ? 1691b
106.6 ? 17.4b,c
105.5 ? 17.3b,c
388 ? 150b,c
3746 ? 560.4b,c
2.85 ? 3.32b
112 ? 18.4
213 ? 39.8
162 ? 26.6
39.6 ? 14.6
156 ? 23.4
57 ? 66.4
7991 ? 1504
73.3 ? 21.3
73.3 ? 33.4
781 ? 305c
2695 ? 806.1
3.75 ? 4.33
86.8 ? 16.3
145.3 ? 42.7
112.7 ? 51.4
78.0 ? 30.5
112.3 ? 33.6
75 ? 86.6
7330 ? 3510
65.3 ? 35.6
69.3 ? 42.7
548 ? 403
2921 ? 1739
aData from the 3rd National Health and Nutrition Examination Survey (1994) for African American Women living in the Southern United States.
bSignificantly different from Lactose Tolerant group (p ? 0.001, ANOVA).
cSignificantly different from NHANES III group (p ? 0.001, ANOVA).
Fig. 1. Percentage contribution of calcium sources in diet of African American women according to self-reported food intake.
Lactose Intolerance and Calcium Intake
50VOL. 21, NO. 1
A similar study conducted at the Mayo Clinic with control of
ethnic background  found that intake of both lactose and
calcium in lactase deficient subjects was significantly lower
than in the lactase sufficient group. Carrocio et al.  found
a lower daily milk intake and a lower daily calcium intake in
lactose maldigesters and intolerant individuals. Results of the
present study confirm that self-imposed restriction may lead to
decreased calcium intake. Indeed, African American women
who reported symptoms of intolerance to a 25 g challenge dose
of lactose had significantly lower intake of calcium than lactose
In addition to lower calcium intake in lactose intolerance,
there is a possibility that undigested lactose in the small intes-
tine may affect calcium bioavailability. Previous reports of
calcium absorption in lactose tolerant and intolerant subjects
have been rather conflicting. While some reports suggest that
lactose or products of its hydrolysis, galactose and glucose,
facilitate calcium absorption [35, 36], another study reported
that calcium absorption was significantly greater in lactase
insufficiency . Nevertheless, the present consensus appears
to be that adult-onset lactase decline might have an indirect
impact on calcium bioavailability by interfering with calcium
absorption . Furthermore, as postulated by Nordin ,
calcium requirement may depend on intake of other nutrients
such as protein, sodium, and vitamin D. Women in our study
had higher than recommended intakes of protein and sodium
but lower intakes of vitamin D, and this was likely to have an
impact on their calcium requirement.
Table 3. Multiple Regression Model results for Calcium Intake in Lactose Tolerant and Lactose Intolerant African American
Calcium Intake (mg/1,000 kcal/day)
Body Mass Index (kg/m2)
Body Mass Index (kg/m2)
Codes for lactose tolerance: 0 — lactose intolerant (LI), 1 — lactose tolerant (LT).
Fig. 2. Relation of total daily calcium intake and body mass index in African American women lactose malabsorbers according to self-reported
tolerance of milk and dairy products. A positive relationship was observed between calcium intake and BMI (see Table 3 for corresponding analysis).
Calcium intake was higher on average in lactose tolerant (LT) than in lactose intolerant (LI) women (regression coefficient ? 208.5). Regression
equations: Calcium intake (mg/1,000 kcal/day) ? 505.23 ? 11.47 ? BMI (kg/m2)? 208.5 ? lactose tolerance; (R2? 0.605), which is significantly
different from lactose intolerant (LI) group (p ? 0.001).
Lactose Intolerance and Calcium Intake
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION51
We  and others [11,13,18] have shown that symptoms
associated with lactose maldigestion can be affected by
changes in nutritional habits. For example, consumption of
milk with solid foods can mitigate symptoms in many individ-
uals and ensure adequate calcium intake . In the present
study, the majority of calcium in lactose intolerant women
came from mixed foods containing low amount of calcium
mostly from added dairy products such as pastas, selected fast
foods, baked goods and sweets. We suggest that African Amer-
ican women who are lactose intolerant choose dairy foods that
are high in calcium but low in lactose such as exogenous
lactase treated milk, yogurts and microbial lactase treated yo-
gurts, and cheeses that do not contain or contain a low amount
of lactose. In addition, these foods could be consumed with
meals so as to reduce gastrointestinal symptoms [13, 40]. These
maneuvers may help many lactose maldigesters and promote
their ability to continue or increase their consumption of dairy
products without or with minimal symptoms. Alternative cal-
cium sources like fortified fruit juices and other calcium-
fortified products may be recommended for lactose intolerant
and dairy product intolerant African American women. Cal-
cium supplements as a major source of dietary calcium should
be considered only for women with severe gastrointestinal
symptoms and low intakes of calcium from foods.
It has been recently postulated that low calcium diets favor
increased adipose tissue energy storage and the converse is true
for high calcium intake . In our study, women who had
higher intake of calcium had significantly lower BMI than
women with lower intakes of calcium. Davis et al.  reeval-
uated five clinical studies of calcium intake in women to
explore associations between calcium intake and body weight.
They found a negative association between calcium intake and
weight, and calculated that the odds ratio for being overweight
was 2.25 for young women in the lower half of calcium intake.
These authors estimated that a 1000-mg difference in calcium
intake was associated with an 8 kg difference in mean body
weight and that variations in calcium intake could account for
approximately 3% of the variance in body weight. It has been
shown that a low calcium intake tends to be a marker for a poor
diet and that a poor diet is good predictor of obesity [24, 41].
The relationship between calcium intake and body weight was
stronger when calcium intake was corrected for energy intake.
The association between high BMI and low calcium intake
observed in this study may be related to other nutritional factors
such as eating habits and/or patterns and physical activity
which we did not control for in this study. Body weight is a
highly multifactorial variable, and it is very likely that only a
fraction of its variability seen in this study could be attributed
to calcium intake. Nevertheless, the association between cal-
cium intake and BMI was stronger when calcium intake was
expressed as density. This might suggest that women with
lower energy intake might benefit more from high calcium
intake and control weight better than women with higher en-
ergy intake. Indeed, it has been postulated that higher energy
intakes could overwhelm the impact of calcium on changes in
body composition in adult women . Hence, it would be
beneficial to conduct a clinical trial in which all these factors
will be controlled for and in which weight change would be the
primary outcome variable.
The findings of this study have to be assessed in the context
of our experimental design. First, we used seven-day dietary
records to assess dietary intake. In order to minimize inheritent
problems with dietary records previously described , we
provided subjects with detailed instruction and contacted them
when problems with interpretation of a record occurred. Al-
though some misreporting was possible, intakes of energy and
nutrients in our study are similar to results reported in
NHANES III for African American women in Southern U.S.
(Table 2). Nevertheless, we tried not to over interpret the
results of intake analysis. Secondly, we did not assess bone
density or bone turnover ratio in our study participants. Previ-
ous studies, however, failed to detect any adverse effects of
lactose maldigestion and decreased calcium absorption on bone
density [22, 43–44]. It is probable that any adverse effect of
lactose maldigestion on bone density is due to reduction in
calcium intake via milk avoidance rather than to impaired
absorption of ingested calcium . Recently, it has been
postulated that lactose maldigestion acts as a risk factor for
osteoporotic bone loss in symptomatic individuals with lactose
intolerance and very low calcium intakes [23, 31]. Some stud-
ies found that bone mineral density and calcium intake were
lower in women with both lactose maldigestion and intolerance
. These reports infer that hypolactasia could predispose a
person to osteoporosis through either reduced intake of milk
secondary to lactose intolerance or impaired calcium absorp-
tion. Osteoporosis is common in lactase deficiency [45–46],
suggesting a link between adult-onset lactase decline and in-
creased risk of this condition which is characterized by de-
creased bone mass, enhanced bone fragility and consequent
increase in fracture risk . Thus it would appear that the
association between lactose ingestion and osteoporosis is most
likely due to the inadequate calcium intake resulting from a
reduced intake of milk and dairy products as a result of lactose
maldigestion and intolerance. The observation that African
Americans have a low prevalence of osteoporosis and relatively
low calcium intake appears to argue against this relationship
. However, the greater bone density observed in African
Americans at maturity would offer relative protection from
osteoporosis later in life despite the presence of lactase insuf-
Finally, in our analysis we did not control for factors linked
to increased BMI in women such as previous pregnancy, ac-
tivity level, family history of obesity and diabetes, and other
environmental factors. Nevertheless, it is well known that low
calcium intakes are linked to pathogenesis of osteoporosis,
hypertension, colon cancer, renolithiasis and possibly obesity
in African American women [8, 25, 35].
Lactose Intolerance and Calcium Intake
52VOL. 21, NO. 1
In this study, we have shown that among lactose maldigest-
ing African American women after adjusting for age and
weight, lactose intolerant women have lower calcium intakes
than those who are lactose tolerant. Lactose maldigesting in-
tolerant women also had a higher BMI than lactose tolerant
women. We conclude that, in premenopausal African American
women, lactose maldigestion accompanied by lactose intoler-
ance is associated with low levels of calcium intake. Possible
impact of this phenomenon on the observed increased BMI in
this population requires further studies.
This work was supported by grants from the National In-
stitutes of Health HL-03530 (to M.S.B.), General Clinical
Research Center Grant RR-1179204 (to Meharry Medical Col-
lege), Clinical Nutrition Research Unit Grant DK-26657 (to
Vanderbilt University), and Meharry COE grant (to M.S.B.).
We thank LeMonica Lewis for her technical help and assis-
tance in preparing this manuscript. Finally, we acknowledge
our subjects for their enthusiasm and participation in this study.
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Received August 16, 2001; revision accepted October 24, 2001.
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