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Obesity and overweight in South African primary school children -- the Health of the Nation Study.

OBJECTIVES: To determine the prevalence of overweight and obesity in a sample of South African children aged 6 - 13 years. DESIGN: Random sampling of schools within each provincial and socio-economic category. SETTING: Primary school children from 5 South African provinces. SUBJECTS: 10 195 (5 611 male and 4 584 female) primary school children. OUTCOME MEASURE: Height and weight were measured and body mass index (BMI) (weight (kg)/height (m) (2)) was calculated for each grouping (age x gender x ethnic group). Cut-off points for BMI defining obese and overweight for gender and age (6 - 13 years) were calculated in accordance with international standards. RESULTS: There were significant differences in height and mass between the different ethnic groups and genders. This trend was not evident for the BMI values. The prevalence of obesity within the sample was 3.2% for boys and 4.9% for girls, whereas overweight prevalence was 14.0% for boys and 17.9% for girls. When the contribution of each ethnic group was adjusted to the demographics of South Africa these values were only slightly different. The prevalence of obesity and overweight among boys was 2.4% and 10.9% respectively, while obese and overweight girls comprised 4.8% and 17.5%, respectively. CONCLUSIONS: South African children show trends of obesity and overweight, similar to values in developed countries about 10 years ago. Intervention strategies to combat an increasingly sedentary lifestyle may need to be developed for the South African context.

Adolescent↗

[Effect of nutritional status during infancy and childhood on the risk of overweight and obesity in adulthood].

OBJECTIVE: To examine the association between fetal nutritional status and overweight and obesity in their adulthood and to provide evidence for formulation of the strategy on preventing low birth weight. METHODS: Using data from 2002 Nationwide Nutrition and Health Survey to set up a case-control method in order to compare body mass index(BMI), prevalence of overweight and obesity as well as to calculate odds ratio of overweight and obesity of case group compared with control group. Three case groups were selected from those who were born in 1959, 1960,1961 respectively, and the controls were those who were born in 1964. RESULTS: The health consequence of being famines on adulthood was evident in women. Means of BMI in women were significantly higher in three case groups than that in control group(P<0.01). After adjustment on geographic regions, the prevalence of overweight in women was significantly higher in three case groups than that in control group(P< 0.01). The prevalence rates of obesity were significantly higher in 1959, 1960 groups than 1964 group(P< 0.05). The odds ratios of overweight of women in three case groups were 28.9% (95% CI:1.063-1.565), 37.2% (95% CI:1. 136-1.658) and 35.2% (95% CI: 1. 103-1.657) respectively, all higher than that in the control group. The odds ratios of obesity of women born in 1959, 1960 groups were 46.5% (95% CI: 1.088-1.972) and 39.6% (95% CI: 1.039- 1.876) respectively, higher than that in the 1964 group. However, such differences were not found in men. CONCLUSION: Higher risks of overweight and obesity in women were caused by malnutrition during their fetal lives. A strategy on preventing low birth weight should be formulated by the government to prevent the chronic disease in adulthood.

Adult↗

Impact of overweight on the risk of developing common chronic diseases during a 10-year period.

BACKGROUND: Overweight adults are at an increased risk of developing numerous chronic diseases. METHODS: Ten-year follow-up (1986-1996) of middle-aged women in the Nurses' Health Study and men in the Health Professionals Follow-up Study to assess the health risks associated with overweight. RESULTS: The risk of developing diabetes, gallstones, hypertension, heart disease, and stroke increased with severity of overweight among both women and men. Compared with their same-sex peers with a body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) between 18.5 and 24.9, those with BMI of 35.0 or more were approximately 20 times more likely to develop diabetes (relative risk [RR], 17.0; 95% confidence interval [CI], 14.2-20.5 for women; RR, 23.4; 95% CI, 19.4-33.2 for men). Women who were overweight but not obese (ie, BMI between 25.0 and 29.9) were also significantly more likely than their leaner peers to develop gallstones (RR, 1.9), hypertension (RR, 1.7), high cholesterol level (RR, 1.1), and heart disease (RR, 1.4). The results were similar in men. CONCLUSIONS: During 10 years of follow-up, the incidence of diabetes, gallstones, hypertension, heart disease, colon cancer, and stroke (men only) increased with degree of overweight in both men and women. Adults who were overweight but not obese (ie, 25.0 < or = BMI < or = 29.9) were at significantly increased risk of developing numerous health conditions. Moreover, the dose-response relationship between BMI and the risk of developing chronic diseases was evident even among adults in the upper half of the healthy weight range (ie, BMI of 22.0-24.9), suggesting that adults should try to maintain a BMI between 18.5 and 21.9 to minimize their risk of disease.

Body Mass Index↗

An 18-year follow-up of overweight and risk of Alzheimer disease.

BACKGROUND: Overweight and obesity are epidemic in Western societies and constitute a major public health problem because of adverse effects on vascular health. Vascular factors may play a role in the development of a rapidly growing disease of late life, Alzheimer disease (AD). Using body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters), we examined whether overweight is a risk factor for dementia and AD. METHODS: The relationship between BMI and dementia risk was investigated in a representative cohort of 392 nondemented Swedish adults who were followed up from age 70 to 88 years, with the use of neuropsychiatric, anthropometric, and other measurements. Multivariate Cox proportional hazards regression analyses included BMI, blood pressure, cardiovascular disease, cigarette smoking, socioeconomic status, and treatment for hypertension. RESULTS: During the 18-year follow-up (4184.8 risk-years), 93 participants were diagnosed as having dementia. Women who developed dementia between ages 79 and 88 years were overweight, with a higher average BMI at age 70 years (27.7 vs 25.7; P =.007), 75 years (27.9 vs 25.0; P<.001), and 79 years (26.9 vs 25.1; P =.02) compared with nondemented women. A higher degree of overweight was observed in women who developed AD at 70 years (29.3; P =.009), 75 years (29.6; P<.001), and 79 years (28.2; P =.003) compared with nondemented women. For every 1.0 increase in BMI at age 70 years, AD risk increased by 36%. These associations were not found in men. CONCLUSIONS: Overweight is epidemic in Western societies. Our data suggest that overweight at high ages is a risk factor for dementia, particularly AD, in women. This may have profound implications for dementia prevention.

Aged↗

Body mass index and overweight in adolescents in 13 European countries, Israel, and the United States.

OBJECTIVE: To compare the body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) and the prevalence of BMI at or above the 85th centile and 95th centile (overweight) in adolescents. DESIGN: Cross-sectional, nationally representative school-based surveys in 1997-1998 by means of identical data collection methods. SETTING: Austria, Czech Republic, Denmark, Flemish Belgium, Finland, France, Germany, Greece, Lithuania, Ireland, Israel, Portugal, Slovakia, Sweden, and the United States. PARTICIPANTS: A total of 29 242 boys and girls, aged 13 and 15 years. MAIN OUTCOME MEASURES: The BMI, BMI at or above the 85th centile, and BMI at or above the 95th centile (overweight) from self-reported height and weight. RESULTS: The highest prevalence of overweight was found in the United States and the lowest in Lithuania. On the basis of the study reference standard, the prevalence of overweight (percentage) in the United States was 12.6% in 13-year-old boys, 10.8% in 13-year-old girls, 13.9% in 15-year-old boys, and 15.1% in 15-year-old girls, all significantly increased. Prevalence of overweight in Lithuania was significantly below the expected 5%, with 1.8% in 13-year-old boys, 2.6% in 13-year-old girls, 0.8% in 15-year-old boys, and 2.1% in 15-year-old girls. Relative rankings among countries were similar for BMI at or above the 85th centile, although there were less dramatic differences at this level. CONCLUSIONS: The highest prevalences of overweight were found in the United States, Ireland, Greece, and Portugal.

Adolescent↗

Prevention of the epidemic increase in child risk of overweight in low-income schools: the El Paso coordinated approach to child health.

OBJECTIVE: To assess the impact on children's health of translating an evidence-based national intervention trial (Child and Adolescent Trial for Cardiovascular Health [CATCH]) to low-income elementary schools with primarily Hispanic students. DESIGN: An untreated, matched control group design with repeated dependent pretest and posttest samples was used. SETTING: Four El Paso CATCH and 4 control elementary schools in El Paso, Tex, along the US-Mexico border region. All had Title I status (most were low-income students). PARTICIPANTS: Participants were 896 third-grade children (473 control schools [224 girls and 249 boys] and 423 CATCH schools [199 girls and 224 boys]); 93% were Hispanic. INTERVENTION: Community-based implementation of the national CATCH program. MAIN OUTCOME MEASURES: Risk of overweight or overweight, body mass index, waist-to-hip ratio, yards run in 9 minutes, passing rates for Fitnessgram national mile standards, moderate to vigorous physical activity and vigorous physical activity in physical education class, and percentage of fat and sodium in school lunches. RESULTS: Girls in control schools had significant increases in percentage of risk of overweight or overweight from third (26%) to fifth (39%) grades, as did girls in CATCH schools (30%-32%); however, the rate of increase for girls in the CATCH schools was significantly lower (2%) compared with the rate for control girls (13%). A similar pattern was seen for boys, with a rate of increase for boys in CATCH schools of 1% (40%-41%), which was significantly less than the 9% increase (40% to 49%) for control boys. CONCLUSIONS: The translation of the national CATCH program to low-income schools with Hispanic students successfully slowed the epidemic increase in risk of overweight or overweight seen in control school children. An emphasis should be placed on community organizing and evaluation feedback when implementing evidence-based school health programs in low-income Hispanic communities.

Anthropometry↗

Neighborhood safety and overweight status in children.

OBJECTIVE: To determine if there is a relationship between parental perception of neighborhood safety and overweight at the age of 7 years. DESIGN: Cross-sectional analysis of the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development. SETTING: Ten urban and rural US sites. PARTICIPANTS: A total of 768 children selected via conditional random sampling with complete data at follow-up. MAIN OUTCOME MEASURES: Parents reported demographics and perception of neighborhood safety by standardized questionnaire. Child overweight status was defined as a body mass index greater than or equal to the 95th percentile for age and sex from measured anthropometrics at the age of 7 years. The base model included relationship of the safety reporter to the child, sex, and baseline body mass index z score at the age of 4.5 years. Covariates tested included maternal marital status, education, and depressive symptoms; child race/ethnicity; participation in structured after-school activities; Home Observation for Measurement of the Environment total score; and neighborhood social cohesiveness. RESULTS: The sample was 85% white, and 10% of the children were overweight. Neighborhood safety ratings in the lowest quartile were independently associated with a higher risk of overweight at the age of 7 years compared with safety ratings in the highest quartile (adjusted odds ratio, 4.43; 95% confidence interval, 2.03-9.65). None of the candidate covariates altered the relationship between perception of neighborhood safety and child overweight status. CONCLUSIONS: Perception of the neighborhood as less safe was independently associated with an increased risk of overweight at the age of 7 years. Public health efforts may benefit from policies directed toward improving both actual and perceived neighborhood safety.

Body Mass Index↗

Increasing prevalences of overweight and obesity in Northern Plains American Indian children.

OBJECTIVES: To report prevalences of overweight and obesity in a large sample of American Indian children from a survey in 2002-2003, and to evaluate the change in prevalences since 1995-1996 when children on the same reservations were measured. DESIGN: Analysis of survey data. SETTING: Aberdeen Area Indian Health Service (North Dakota, South Dakota, Iowa, and Nebraska). PARTICIPANTS: A total of 11 538 American Indian children (aged 5-17 years) attending 55 schools on 12 reservations. MAIN OUTCOME MEASURE: Height and weight measured during the 2002-2003 school year by the same team as in the earlier survey. Prevalences of overweight (> or =85th percentile) and obesity (> or =95th percentile) were calculated on the basis of body mass index (calculated as weight in kilograms divided by the square of height in meters) and the Centers for Disease Control and Prevention growth charts. RESULTS: At 5 years of age, 47% of boys and 41% of girls were overweight, and 24% of the children were obese. Prevalences of overweight and obesity exceeded those for the most recent available data for all US children at almost every age. In the intervening 7 to 8 years between surveys, prevalences of overweight and obesity continued to increase in the children by 4.5% and 4.3%, respectively. CONCLUSIONS: Prevalences of overweight and obesity in the most recent sample of American Indian children indicate that they are at even higher risk for these conditions and their health-related sequelae than the best estimates for all US children, with prevalences as high as or higher than those for any other racial or ethnic groups of children reported in the most recent national surveys.

Adolescent↗

Overweight prevalence and trends for children and adolescents. The National Health and Nutrition Examination Surveys, 1963 to 1991.

OBJECTIVE: To examine prevalence of overweight and trends in overweight for children and adolescents in the US population. DESIGN: Nationally representative cross-sectional surveys with an in-person interview and a medical examination, including measurement of height and weight. PARTICIPANTS: Between 3000 and 14,000 youths aged 6 through 17 years examined in each of five separate national surveys during 1963 to 1965, 1966 to 1970, 1971 to 1974, 1976 to 1980, and 1988 to 1991 (Cycles II and III of the National Health Examination Survey, and the first, second, and third National Health and Nutrition Examination Surveys, respectively). MAIN OUTCOME MEASURES: Prevalence of overweight based on body mass index and 85th or 95th percentile cutoff points from Cycles II and III of the National Health Examination Survey. RESULTS: From 1988 to 1991, the prevalence of overweight was 10.9% based on the 95th percentile and 22% based on the 85th percentile. Overweight prevalence increased during the period examined among all sex and age groups. The increase was greatest since 1976 to 1980, similar to findings previously reported for adults in the United States. CONCLUSIONS: Increasing overweight among youths implies a need to focus on primary prevention. Attempts to increase physical activity may provide a means to address this important public health problem.

Adolescent↗

Food consumption, activity, and overweight among elementary school children in an Appalachian Kentucky community.

In the U.S., child overweight is on the rise and is implicated in later adult chronic illness. Given that overweight is hardly tractable, prevention as compared to treatment is seen as a better alternative for lowering the risk of long-term health consequences. To increase the success of prevention efforts, many argue that programs must be "culturally sensitive and targeted toward specific populations at greater risk. However, there exists a limited understanding of how overweight is distributed across the landscape, among and within populations and groups. This paper reports the prevalence of overweight among 54 school children in a rural, Appalachian community with a high rate of poverty, and it compares boys to girls. Thirty-seven percent of boys and 10.3% of girls are overweight, based on the 90th percentile body mass index (BMI). Analysis of food intake indicates a pattern of food consumption that is high in fatty and sugary foods and low in fruit and vegetable consumption. Analysis of activity indicates that children report more low-intensity activity than high; that overweight children report more episodes of video/computer play compared to nonoverweight children; and that boys spend more time than girls in front of the computer/television screen.

Activities of Daily Living↗

Global and dimensional self-esteem in preadolescent and early adolescent children who are overweight: age and gender differences.

OBJECTIVE: To examine age and gender differences in global and dimensional self-esteem in children who are overweight. METHOD: As part of a pretreatment assessment, the Perceived Competence Scale for Children was completed by 121 children (ages 8-14) who were overweight and enrolling in a weight reduction program. RESULTS: Gender differences in general self-esteem and age differences in physical self-esteem were found. Also, girls who were highly overweight reported lower physical self-esteem than girls who were moderately overweight. However, for boys, the opposite pattern emerged. For both boys and girls, cognitive and social self-esteem predicted general self-esteem and physical self-esteem did not. DISCUSSION: Children who are overweight may emphasize dimensions of their self-esteem in nongender stereotyped ways that are protective of their general self-esteem. Understanding developmental trends and gender differences in self-esteem can enhance our ability to assist youth who are overweight in maintaining favorable self-evaluations.

Adolescent↗

Correlations with self-reported weight loss in overweight U.S. adults.

The authors investigated two issues among overweight men and women in the U.S.: 1) what is the influence of the self-expressed intention to lose weight in the presence of other potential predictors of loss and 2) what are easily identifiable predictors of intentional weight loss during a 1-year recall period. The sample consisted of 1996 overweight men (body mass index (BMI > or = 27.8 kg/m2) and 2586 overweight women (BMI > or = 27.3 kg/m2) who answered questions regarding 1-year weight change in a Current Health Topic supplement of the population-based 1989 National Health Interview Survey. Of these overweight persons, 56.8% of men and 72.1% of women attempted to lose weight during the previous year. The most important characteristic associated with weight loss was the expressed intention itself. For any weight loss, the odds ratios (95% confidence intervals) for intention were 4.6 (3.6-5.9) for men and 3.8 (2.8-5.0) for women. Controlling for other factors reduced the odds only slightly, to 4.3 for men and 3.5 for women. Among women, older age, having a greater frequency of blood pressure checks, and being in poorer health reduced the influence of intent as a predictor of loss. To address the second objective, the identification of predictors of intentional 1-year weight loss, analysis was restricted to overweight persons who attempted to lose weight. For both sexes, statistically significant predictors (p < 0.05) included never being married, smoking, higher BMI, being diabetic, and having a higher number of blood pressure checks. Being divorced or separated was predictive of weight loss in men only. Also, men were more likely to achieve weight loss than women. In conclusion, 1-year weight loss among the overweight was primarily a function of the intention to lose weight, although other factors contributed to determine whether weight loss was achieved.

Adolescent↗

Effects of a beta3-adrenergic agonist on glucose uptake and leptin expression and secretion in cultured adipocytes from lean and overweight (cafeteria) rats.

The increase in body and white adipose tissue weights induced by a high-fat diet were prevented by treatment with the beta3-adrenergic agonist Trecadrine. Plasma insulin levels were slightly elevated in overweight rats, while a decrease was observed in Trecadrine-treated groups. Insulin-dependent glucose uptake was impaired in adipocytes of the overweight rats in relation to lean animals. The beta3-adrenergic agonist induced an increase in insulin-stimulated glucose uptake by adipocytes as compared to the nontreated animals. In fact, Trecadrine treatment was able to restore to control values the impairment in insulin-mediated glucose uptake induced by the cafeteria diet, suggesting that Trecadrine prevents the development of insulin resistance in overweight animals. Basal leptin secretion was increased in adipocytes of the overweight rats in relation to lean animals. Trecadrine treatment induced a decrease in basal leptin secretion compared to the untreated animals. Insulin-stimulated leptin secretion reached similar levels in adipocytes of the overweight rats as in lean animals. There was a trend for insulin-induced leptin secretion to be lower at 24 h in Trecadrine-treated rats, but it did not reach statistical significance. In conclusion, adipocytes of diet-induced overweight animals have a higher basal leptin secretion, which is reduced by treatment with Trecadrine. However, neither the cafeteria diet nor the Trecadrine treatment significantly alters the ability of adipocytes to increase leptin secretion in response to insulin.

Adipocytes↗

The prevalence of overweight adults living in a rural and remote community. The Bella Coola Valley.

OBJECTIVE: To determine the prevalence of overweight adults living in the Bella Coola Valley. DESIGN: A retrospective chart review of all people attending the Bella Coola Medical Clinic, and residing in the Bella Coola Valley. MAIN OUTCOME MEASURES: Weight (killograms) and body mass index (BMI). RESULTS: More than 92% of clinic charts had a recent measurement of weight and 65% of clinic charts had height measured; accordingly, we were able to calculate the BMI on 65% of the clinic population. Over 50% of the adults residing in the Bella Coola Valley are considered overweight (BMI > 27, the Health Canada definition) and only 25% have a BMI within an acceptable range (20.0 to 24.9). Proportionately more Aboriginal people are overweight (65%) than non-Aboriginal people (47%); men and women were similarly overweight (56% and 53%, respectively); and proportionately more people were overweight with increased age. The prevalence of being overweight in people aged 65 years and older is 66%. As weight increased so did the prevalence of diabetes mellitus, hypertension, hypercholesterolemia, diverticular disease, dyspepsia/gastroesophageal reflux disease (GERD), alcohol issues, asthma, depression, coronary artery disease, and eczematous dermatitis. There was no relationship between increasing weight and atrial fibrillation, cerebrovascular disease, inflammatory arthritis, hypothyroidism, chronic back/neck pain, peripheral vascular disease, chronic obstructive lung disease, congestive heart failure, and cancer. CONCLUSION: Living in a remote community does not protect against obesity and the complications of obesity. Obesity is present in a greater proportion of Aboriginal people. The treatment and prevention of obesity in rural populations of differing ethnicity may need to be individualized.

Adult↗

Prevalence of overweight and obesity in Austrian male and female farmers.

OBJECTIVES: Risk factors for chronic and degenerative diseases, especially overweight and obesity are rarely examined among farmers. Objective of the study was to determine subjective health and health-related lifestyle among Austrian farmers. METHODS: The study was performed in 1999/2000 as a nationwide survey by mail among all Austrian farmers, men and women, all insured by the Health Insurance Agency of Farmers. RESULTS: 15.2% of the farmers were obese. 42.9% were overweight. The prevalence of overweight and obesity was high amongst 15-19 year olds, and reached a second peak among the age groups 50-59 and 60-69 years old. Geographically, the highest concentration of overweight and obese farmers was found in the eastern, flat regions of Austria and the lowest concentration in the western, mountainous areas of Austria. CONCLUSIONS: Prevalence of overweight and obesity is very high among Austrian farmers, especially when compared to the general population. The results of this study emphasize the need for further work, with respect to the development of prevention strategies to reduce the prevalence of overweight and obesity among Austrian farmers.

Adolescent↗

Synergic effect of overweight and cold on uncoupling proteins expression, a role of alpha(2)/beta(3) adrenergic receptor balance?

The effect of cold exposure, being overweight and their interaction was investigated on the response of uncoupling proteins UCP1, UCP2 and UCP3 and the alpha(2)/beta(3) adrenergic receptor (AR) balance in brown adipose tissue (BAT), as well as the involvement of leptin gene expression in white adipose tissues, in control and overweight male rats of the dietary obesity model known as the post-cafeteria model. UCP1, UCP2 and UCP3 mRNAs were up-regulated by cold, with a synergic effect of cold exposure and being overweight on UCP1 mRNA levels (with the related UCP1 protein response), and with UCP2 mRNA showing a parallel response. Furthermore, the BAT alpha(2)/beta(3) AR ratio was diminished in overweight rats. The results suggest that the UCP1-dependent thermogenic capacity in BAT of post-cafeteria overweight rats has a more sensitive response to cold exposure and that UCP2 and UCP3 could be somehow involved in the thermogenic response but differentially regulated. Moreover, the diminished alpha(2)/beta(3) AR ratio in BAT could be one of the factors involved in the more sensitive response of overweight rats to cold in terms of BAT thermogenesis-related parameters.

Adipose Tissue, Brown↗

Additive effect of overweight and type 2 diabetes in the appearance of coronary heart disease but not of stroke: a cross-sectional study.

We evaluated the possible additive effect of overweight and diabetes in the occurrence of coronary heart disease (CHD) and stroke, and their interaction with other established risk factors. In a cross-sectional study, we evaluated the frequency of CHD and stroke in four groups of subjects: (1) lean non-diabetic subjects (n=250); (2) lean diabetic subjects (n=269); (3) overweight non-diabetic subjects (n=203); and (4) overweight diabetic subjects (n=446). CHD was more frequent among diabetic subjects, and even more among overweight diabetic subjects; stroke was more frequent among diabetic subjects, but equally frequent in overweight and in lean diabetic subjects. At multiple logistic regression analysis, age, arterial hypertension, diabetes were independent risk factors for CHD and for stroke; BMI and hyperlipidemia were risk factors only for CHD. CHD was an independent risk factor for stroke, and stroke was a risk factor for CHD. We conclude that obesity and diabetes are additional risk factors for CHD but not for stroke. The value of established risk factors such as arterial hypertension and hyperlipidemia in determining the appearance of CHD and stroke is maintained in the presence overweight and diabetes. Finally, CHD is frequently associated with stroke, suggesting a common process of atherosclerosis underlying both diseases.

Albuminuria↗

Overweight and chronic illness--a retrospective cohort study, with a follow-up of 6-17 years, in men and women of initially 20-50 years of age.

A retrospective cohort-study with a follow-up of 6-17 years was carried out in four general practices in the Netherlands in the period 1967-1983. In total 317 overweight men and 565 overweight women were followed in a continuous morbidity registration, starting in the year they were diagnosed as overweight (at age 20-50 years). Incidence of illnesses in this group was compared to that in a control group (444 men and 627 women not registered overweight), matched on sex, age and calendar-year at start of follow-up. The incidence of registered morbidity in the overweight group was higher for diabetes, gout, arteriosclerotic disease, arthrosis for men and women, and also for varicose veins for women. Increasing BMI at start of follow-up was associated with increased risk for most illnesses under study. For gout and arteriosclerotic disease in men, overweight appeared to be a risk factor at lower levels of BMI than in women.

Adult↗