Breanna M. Gauthier

An increase in the prevalences of childhood and adolescent obesity in the United States has been documented in a series of national surveys conducted in the last 30 years. These include the National Health Evaluation surveys, NHES II (1963-1965) and NHES III (1966-1970), and the National Health and Nutrition Examination surveys, NHANES I (1971-1974), NHANES II (1976-1980), and NHANES III (1988-1994).^1-4 Obesity in childhood and adolescence may lead to disorders in adulthood, including hypertension, diabetes, coronary heart disease, and some cancers.⁵ The strongest connection between chronic disease and death is linked to adolescent rather than adult obesity.⁶ Between 1980 and 1994 there was a 6% increase in the absolute prevalence of obesity in US children.⁷ Data from NHANES III, the most recent national survey of weight and height in children and adults, showed that 14% of children aged 6 to 11 years and 12% of those aged 12 to 17 years were overweight.⁷

We noticed that the prevalence of obesity in our Michigan primary care practices appeared higher than that reported from national or state surveys. We confirmed our impression by measuring a consecutive sample of 6912 patients in 19 practices in the summer of 1996. Analysis of the adult data revealed that 54.5% of the men and 52.6% of the women were overweight, nearly double the prevalences cited in the 1993 Michigan Behavioral Risk Factor Survey (MBRFS): 29.5% for the men and 28.7% for the women.⁸ MBRFS obesity prevalences are slightly higher than contemporary national prevalences. Comparison with county-specific data from the MBRFS gave the same results. Adjusting the analysis for age, race, socioeconomic status, and chronic diseases associated with obesity such as diabetes and heart disease, did not significantly affect the results. This high prevalence of obesity in primary care patients as compared with population-based surveys has not been previously described, and the reason for it is unknown.

The purpose of our report is to describe the prevalences of obesity in of children and adolescents in our Michigan primary care practices and to compare those prevalences to national and state prevalences. We hypothesized that the children enrolled in our practices would have higher prevalences of obesity than national and state prevalences derived from surveys of community-dwelling populations.

Methods

Practices, Enrollment, and Measurement

We included 19 family practice offices of the Upper Peninsula Research Network (UPRNet) in our study. UPRNet is a family practice research network in rural northern Michigan. These practices are in rural locations, and community populations range from 300 to 15,000. Eleven of the offices are publicly funded community health centers. The populations served are typical of rural northern Michigan, with more than the state average of elderly and poor patients. To include urban and suburban children, we also asked 2 family practice clinics serving middle and lower socioeconomic groups in the Lansing area to participate.

In the spring and early summer of 1996, we invited consecutive patients aged 4 to 17 years visiting any of the participating practices for care to take part in our study, and we obtained informed consent. We chose spring and early summer to avoid those seasons when people wear heavy clothing and boots and to avoid enrolling vacationers who did not reside in the study areas. Patients with appointments specifically to see a dietitian, those known to be pregnant, and those unable to stand on a scale were excluded from the study.

Heights were measured using 1 of 2 methods, depending on the practice ’s preference; either with a measuring arm attached to a wall or with a measuring arm attached to a scale. All measuring arms were checked to be certain they were parallel to the floor. Weights were taken on balance beam scales calibrated less than a month before the study began. Patients removed their coats and shoes; no weight adjustments were made for clothing. Each office nursing staff reviewed the measuring procedures before participating in the study. Trained on-site study coordinators (office managers or nursing managers) supervised the data gathering process to ensure adherence.

The University Committee on Research Involving Human Subjects of Michigan State University approved our study protocol.

Definitions of Obesity in Children and Adolescents

There is no internationally accepted measure to define obesity in children. Methods for classifying childhood and adolescent obesity have been developed on the basis of comparison with growth charts (percentile weight for height by age and sex), percentile of triceps skin fold thickness, and percentile cutoffs for body mass index (BMI). BMI is emerging as the prefer red standard. The Expert Committee on Clinical Guidelines for Overweight in Adolescent Preventive Services⁸ recommends that children and adolescents with a BMI greater than the 85th percentile but less than the 95th be classified as “at risk of overweight” and those with a BMI greater than the 95th percentile be classified as “overweight.” We used that classification system.

For the comparisons, we followed the method used by Troiano.¹ For the baseline standard, he used the BMI distributions derived from the National Health Examination surveys (NHES II for children aged 6 to 11 years and NHES III for children aged 12 to 17 years). He calculated the percentage of children above the 85th and 95th percentile cutoffs of NHES for NHANES I, NHANES II, and NHANES III data. Similarly, we calculated the percentage of children and adolescents in the Michigan primary care practices with BMIs greater than the 85th and 95th percentiles as defined by NHES. For a contemporary regional comparison group, we obtained data from the Kuntzelman Fitness for Youth Program (KFYP), a 1997 statewide survey of Michigan schoolchildren. In that survey, a nonrandom sample of schoolchildren from 41 Michigan school districts were weighed and measured. Because 90% of our primary care patients were white, we used only the data on white children from the KFYP database. We summarized the KFYP data in the same way as the other surveys.

Results

A total of 993 children aged 4 to 17 years were measured and weighed in the Michigan primary care practices. There were 502 boys and 491 girls. Of these patients, 90% were white; 3% were Native American; 3% were African American; 1% was Hispanic; 1% was of another race; and 2% did not state their race. The Table 1 shows the percentage of children in the Michigan primary care practices above the 85th and 95th percentiles based on the NHES data and compared with NHANES data and Michigan schoolchildren (KFYP). The prevalences of obesity in the United States have increased over time, and the patients in our primary care practices have the highest prevalences of obesity in all age and sex groups when compared with the national surveys. For example, for boys aged 6 to 11, the percentage of those overweight in NHANES was 11%, whereas 20% of the Michigan primary care patients in this age group were overweight. In all groups, except for girls aged 6 to 11 years, prevalences of obesity of the primary care patients were greater than those of the Michigan schoolchildren in the KFYP survey.

Discussion

A larger than expected proportion of the children and adolescents in our primary care practices in Michigan are at risk for being overweight or are overweight. The prevalences of obesity in children and adolescents presenting for care in these practices are nearly 2 times greater than the national prevalences measured in NHANES II and NHANES III an d somewhat greater than a contemporary sample of Michigan schoolchildren. The absolute prevalences of obesity in the children and adolescents seen in our primary care practices were 3% to 9% higher than in the Michigan schoolchildren in all age-sex categories, except for girls aged 6 to 11 years.

It is not surprising that obesity is more prevalent in our sample than in the NHANES II and NHANES III surveys; NHANES data was gathered from 1976 to 1980 and 1988 to 1994, respectively, and obesity prevalences are steadily increasing. However, the reason that our patients are more obese than a contemporary sample of Michigan schoolchildren is unknown. The difference may be caused by systematic bias, as neither of the surveys was based on random sampling. However, in the analysis of our adult patients, the prevalence of obesity of patients was much greater than local community prevalences, even after adjusting for socioeconomic status and medical conditions known to be associated with obesity.⁸

The association between overweight and socio-economic status in children and adolescents is weak and not statistically significant.⁹ We speculate that obese children and adolescents have more physical and psychological complaints than healthy-weight individuals, causing them to visit their physicians more frequently. If they visit the practice more frequently, obese patients are more likely to be included in a survey of consecutive patients, thereby explaining the higher prevalences of obesity in primary care patients. Perhaps obese children or their parents are more worried about their health and therefore more likely to visit the physician for minor complaints. However, no association has been found between obesity and mental illness, although research regarding such an association is considered inconclusive at this time.¹⁰

Conclusions

The prevalences of obesity for children and adolescents presenting for care in Michigan primary care practices are higher than the state and national prevalences. Further studies using larger sample sizes, random sampling, and more settings are necessary to confirm or refute our findings. If this prevalence of obesity in primary care patients is confirmed, explanations for the differences should be explored.

Acknowledgments

We would like to thank the following people for their contributions to this study: Charles Kuntzelman, EdD, for providing us with the Michigan schoolchildren data; Nan Kreher, MEd, administration; Teresa Ettenhofer, administration and data analysis; and Kimber Gauthier, Jenny Folcik, and Celeste St. John, data entry. We would also like to thank the UPRNet and Michigan State University clinics that collected data. They are: Alpena Medical Arts, Alpena; Doctors Park Family Physicians, Escanaba; Dr Victoria Macki’s office, Newberry; OSF Medical Group, Gladstone and Escanaba; Gwinn Medical Center, Gwinn; Marquette Medical Clinic, Iron River; Burns Clinic, St Ignace; Alcona Health Center, Lincoln and Ossineke; East Jordan Family Health Center, East Jord an; Ewen Medical Clinic, Ewen; Northern Menominee Health Center, Spalding; Northern Michigan Health Services, Houghton Lake; Michigan State University-Family Practice at Clinical Center site, East Lansing; and Michigan State University-Family Practice at the Family Health Center, St. Lawrence Hospital, Lansing.

An increase in the prevalences of childhood and adolescent obesity in the United States has been documented in a series of national surveys conducted in the last 30 years. These include the National Health Evaluation surveys, NHES II (1963-1965) and NHES III (1966-1970), and the National Health and Nutrition Examination surveys, NHANES I (1971-1974), NHANES II (1976-1980), and NHANES III (1988-1994).^1-4 Obesity in childhood and adolescence may lead to disorders in adulthood, including hypertension, diabetes, coronary heart disease, and some cancers.⁵ The strongest connection between chronic disease and death is linked to adolescent rather than adult obesity.⁶ Between 1980 and 1994 there was a 6% increase in the absolute prevalence of obesity in US children.⁷ Data from NHANES III, the most recent national survey of weight and height in children and adults, showed that 14% of children aged 6 to 11 years and 12% of those aged 12 to 17 years were overweight.⁷

We noticed that the prevalence of obesity in our Michigan primary care practices appeared higher than that reported from national or state surveys. We confirmed our impression by measuring a consecutive sample of 6912 patients in 19 practices in the summer of 1996. Analysis of the adult data revealed that 54.5% of the men and 52.6% of the women were overweight, nearly double the prevalences cited in the 1993 Michigan Behavioral Risk Factor Survey (MBRFS): 29.5% for the men and 28.7% for the women.⁸ MBRFS obesity prevalences are slightly higher than contemporary national prevalences. Comparison with county-specific data from the MBRFS gave the same results. Adjusting the analysis for age, race, socioeconomic status, and chronic diseases associated with obesity such as diabetes and heart disease, did not significantly affect the results. This high prevalence of obesity in primary care patients as compared with population-based surveys has not been previously described, and the reason for it is unknown.

The purpose of our report is to describe the prevalences of obesity in of children and adolescents in our Michigan primary care practices and to compare those prevalences to national and state prevalences. We hypothesized that the children enrolled in our practices would have higher prevalences of obesity than national and state prevalences derived from surveys of community-dwelling populations.

Methods

Practices, Enrollment, and Measurement

We included 19 family practice offices of the Upper Peninsula Research Network (UPRNet) in our study. UPRNet is a family practice research network in rural northern Michigan. These practices are in rural locations, and community populations range from 300 to 15,000. Eleven of the offices are publicly funded community health centers. The populations served are typical of rural northern Michigan, with more than the state average of elderly and poor patients. To include urban and suburban children, we also asked 2 family practice clinics serving middle and lower socioeconomic groups in the Lansing area to participate.

In the spring and early summer of 1996, we invited consecutive patients aged 4 to 17 years visiting any of the participating practices for care to take part in our study, and we obtained informed consent. We chose spring and early summer to avoid those seasons when people wear heavy clothing and boots and to avoid enrolling vacationers who did not reside in the study areas. Patients with appointments specifically to see a dietitian, those known to be pregnant, and those unable to stand on a scale were excluded from the study.

Heights were measured using 1 of 2 methods, depending on the practice ’s preference; either with a measuring arm attached to a wall or with a measuring arm attached to a scale. All measuring arms were checked to be certain they were parallel to the floor. Weights were taken on balance beam scales calibrated less than a month before the study began. Patients removed their coats and shoes; no weight adjustments were made for clothing. Each office nursing staff reviewed the measuring procedures before participating in the study. Trained on-site study coordinators (office managers or nursing managers) supervised the data gathering process to ensure adherence.

The University Committee on Research Involving Human Subjects of Michigan State University approved our study protocol.

Definitions of Obesity in Children and Adolescents

There is no internationally accepted measure to define obesity in children. Methods for classifying childhood and adolescent obesity have been developed on the basis of comparison with growth charts (percentile weight for height by age and sex), percentile of triceps skin fold thickness, and percentile cutoffs for body mass index (BMI). BMI is emerging as the prefer red standard. The Expert Committee on Clinical Guidelines for Overweight in Adolescent Preventive Services⁸ recommends that children and adolescents with a BMI greater than the 85th percentile but less than the 95th be classified as “at risk of overweight” and those with a BMI greater than the 95th percentile be classified as “overweight.” We used that classification system.

For the comparisons, we followed the method used by Troiano.¹ For the baseline standard, he used the BMI distributions derived from the National Health Examination surveys (NHES II for children aged 6 to 11 years and NHES III for children aged 12 to 17 years). He calculated the percentage of children above the 85th and 95th percentile cutoffs of NHES for NHANES I, NHANES II, and NHANES III data. Similarly, we calculated the percentage of children and adolescents in the Michigan primary care practices with BMIs greater than the 85th and 95th percentiles as defined by NHES. For a contemporary regional comparison group, we obtained data from the Kuntzelman Fitness for Youth Program (KFYP), a 1997 statewide survey of Michigan schoolchildren. In that survey, a nonrandom sample of schoolchildren from 41 Michigan school districts were weighed and measured. Because 90% of our primary care patients were white, we used only the data on white children from the KFYP database. We summarized the KFYP data in the same way as the other surveys.

Results

A total of 993 children aged 4 to 17 years were measured and weighed in the Michigan primary care practices. There were 502 boys and 491 girls. Of these patients, 90% were white; 3% were Native American; 3% were African American; 1% was Hispanic; 1% was of another race; and 2% did not state their race. The Table 1 shows the percentage of children in the Michigan primary care practices above the 85th and 95th percentiles based on the NHES data and compared with NHANES data and Michigan schoolchildren (KFYP). The prevalences of obesity in the United States have increased over time, and the patients in our primary care practices have the highest prevalences of obesity in all age and sex groups when compared with the national surveys. For example, for boys aged 6 to 11, the percentage of those overweight in NHANES was 11%, whereas 20% of the Michigan primary care patients in this age group were overweight. In all groups, except for girls aged 6 to 11 years, prevalences of obesity of the primary care patients were greater than those of the Michigan schoolchildren in the KFYP survey.

Discussion

A larger than expected proportion of the children and adolescents in our primary care practices in Michigan are at risk for being overweight or are overweight. The prevalences of obesity in children and adolescents presenting for care in these practices are nearly 2 times greater than the national prevalences measured in NHANES II and NHANES III an d somewhat greater than a contemporary sample of Michigan schoolchildren. The absolute prevalences of obesity in the children and adolescents seen in our primary care practices were 3% to 9% higher than in the Michigan schoolchildren in all age-sex categories, except for girls aged 6 to 11 years.

It is not surprising that obesity is more prevalent in our sample than in the NHANES II and NHANES III surveys; NHANES data was gathered from 1976 to 1980 and 1988 to 1994, respectively, and obesity prevalences are steadily increasing. However, the reason that our patients are more obese than a contemporary sample of Michigan schoolchildren is unknown. The difference may be caused by systematic bias, as neither of the surveys was based on random sampling. However, in the analysis of our adult patients, the prevalence of obesity of patients was much greater than local community prevalences, even after adjusting for socioeconomic status and medical conditions known to be associated with obesity.⁸

The association between overweight and socio-economic status in children and adolescents is weak and not statistically significant.⁹ We speculate that obese children and adolescents have more physical and psychological complaints than healthy-weight individuals, causing them to visit their physicians more frequently. If they visit the practice more frequently, obese patients are more likely to be included in a survey of consecutive patients, thereby explaining the higher prevalences of obesity in primary care patients. Perhaps obese children or their parents are more worried about their health and therefore more likely to visit the physician for minor complaints. However, no association has been found between obesity and mental illness, although research regarding such an association is considered inconclusive at this time.¹⁰

Conclusions

The prevalences of obesity for children and adolescents presenting for care in Michigan primary care practices are higher than the state and national prevalences. Further studies using larger sample sizes, random sampling, and more settings are necessary to confirm or refute our findings. If this prevalence of obesity in primary care patients is confirmed, explanations for the differences should be explored.

Acknowledgments

We would like to thank the following people for their contributions to this study: Charles Kuntzelman, EdD, for providing us with the Michigan schoolchildren data; Nan Kreher, MEd, administration; Teresa Ettenhofer, administration and data analysis; and Kimber Gauthier, Jenny Folcik, and Celeste St. John, data entry. We would also like to thank the UPRNet and Michigan State University clinics that collected data. They are: Alpena Medical Arts, Alpena; Doctors Park Family Physicians, Escanaba; Dr Victoria Macki’s office, Newberry; OSF Medical Group, Gladstone and Escanaba; Gwinn Medical Center, Gwinn; Marquette Medical Clinic, Iron River; Burns Clinic, St Ignace; Alcona Health Center, Lincoln and Ossineke; East Jordan Family Health Center, East Jord an; Ewen Medical Clinic, Ewen; Northern Menominee Health Center, Spalding; Northern Michigan Health Services, Houghton Lake; Michigan State University-Family Practice at Clinical Center site, East Lansing; and Michigan State University-Family Practice at the Family Health Center, St. Lawrence Hospital, Lansing.

An increase in the prevalences of childhood and adolescent obesity in the United States has been documented in a series of national surveys conducted in the last 30 years. These include the National Health Evaluation surveys, NHES II (1963-1965) and NHES III (1966-1970), and the National Health and Nutrition Examination surveys, NHANES I (1971-1974), NHANES II (1976-1980), and NHANES III (1988-1994).^1-4 Obesity in childhood and adolescence may lead to disorders in adulthood, including hypertension, diabetes, coronary heart disease, and some cancers.⁵ The strongest connection between chronic disease and death is linked to adolescent rather than adult obesity.⁶ Between 1980 and 1994 there was a 6% increase in the absolute prevalence of obesity in US children.⁷ Data from NHANES III, the most recent national survey of weight and height in children and adults, showed that 14% of children aged 6 to 11 years and 12% of those aged 12 to 17 years were overweight.⁷

We noticed that the prevalence of obesity in our Michigan primary care practices appeared higher than that reported from national or state surveys. We confirmed our impression by measuring a consecutive sample of 6912 patients in 19 practices in the summer of 1996. Analysis of the adult data revealed that 54.5% of the men and 52.6% of the women were overweight, nearly double the prevalences cited in the 1993 Michigan Behavioral Risk Factor Survey (MBRFS): 29.5% for the men and 28.7% for the women.⁸ MBRFS obesity prevalences are slightly higher than contemporary national prevalences. Comparison with county-specific data from the MBRFS gave the same results. Adjusting the analysis for age, race, socioeconomic status, and chronic diseases associated with obesity such as diabetes and heart disease, did not significantly affect the results. This high prevalence of obesity in primary care patients as compared with population-based surveys has not been previously described, and the reason for it is unknown.

The purpose of our report is to describe the prevalences of obesity in of children and adolescents in our Michigan primary care practices and to compare those prevalences to national and state prevalences. We hypothesized that the children enrolled in our practices would have higher prevalences of obesity than national and state prevalences derived from surveys of community-dwelling populations.

Methods

Practices, Enrollment, and Measurement

We included 19 family practice offices of the Upper Peninsula Research Network (UPRNet) in our study. UPRNet is a family practice research network in rural northern Michigan. These practices are in rural locations, and community populations range from 300 to 15,000. Eleven of the offices are publicly funded community health centers. The populations served are typical of rural northern Michigan, with more than the state average of elderly and poor patients. To include urban and suburban children, we also asked 2 family practice clinics serving middle and lower socioeconomic groups in the Lansing area to participate.

In the spring and early summer of 1996, we invited consecutive patients aged 4 to 17 years visiting any of the participating practices for care to take part in our study, and we obtained informed consent. We chose spring and early summer to avoid those seasons when people wear heavy clothing and boots and to avoid enrolling vacationers who did not reside in the study areas. Patients with appointments specifically to see a dietitian, those known to be pregnant, and those unable to stand on a scale were excluded from the study.

Heights were measured using 1 of 2 methods, depending on the practice ’s preference; either with a measuring arm attached to a wall or with a measuring arm attached to a scale. All measuring arms were checked to be certain they were parallel to the floor. Weights were taken on balance beam scales calibrated less than a month before the study began. Patients removed their coats and shoes; no weight adjustments were made for clothing. Each office nursing staff reviewed the measuring procedures before participating in the study. Trained on-site study coordinators (office managers or nursing managers) supervised the data gathering process to ensure adherence.

The University Committee on Research Involving Human Subjects of Michigan State University approved our study protocol.

Definitions of Obesity in Children and Adolescents

There is no internationally accepted measure to define obesity in children. Methods for classifying childhood and adolescent obesity have been developed on the basis of comparison with growth charts (percentile weight for height by age and sex), percentile of triceps skin fold thickness, and percentile cutoffs for body mass index (BMI). BMI is emerging as the prefer red standard. The Expert Committee on Clinical Guidelines for Overweight in Adolescent Preventive Services⁸ recommends that children and adolescents with a BMI greater than the 85th percentile but less than the 95th be classified as “at risk of overweight” and those with a BMI greater than the 95th percentile be classified as “overweight.” We used that classification system.

For the comparisons, we followed the method used by Troiano.¹ For the baseline standard, he used the BMI distributions derived from the National Health Examination surveys (NHES II for children aged 6 to 11 years and NHES III for children aged 12 to 17 years). He calculated the percentage of children above the 85th and 95th percentile cutoffs of NHES for NHANES I, NHANES II, and NHANES III data. Similarly, we calculated the percentage of children and adolescents in the Michigan primary care practices with BMIs greater than the 85th and 95th percentiles as defined by NHES. For a contemporary regional comparison group, we obtained data from the Kuntzelman Fitness for Youth Program (KFYP), a 1997 statewide survey of Michigan schoolchildren. In that survey, a nonrandom sample of schoolchildren from 41 Michigan school districts were weighed and measured. Because 90% of our primary care patients were white, we used only the data on white children from the KFYP database. We summarized the KFYP data in the same way as the other surveys.

Results

A total of 993 children aged 4 to 17 years were measured and weighed in the Michigan primary care practices. There were 502 boys and 491 girls. Of these patients, 90% were white; 3% were Native American; 3% were African American; 1% was Hispanic; 1% was of another race; and 2% did not state their race. The Table 1 shows the percentage of children in the Michigan primary care practices above the 85th and 95th percentiles based on the NHES data and compared with NHANES data and Michigan schoolchildren (KFYP). The prevalences of obesity in the United States have increased over time, and the patients in our primary care practices have the highest prevalences of obesity in all age and sex groups when compared with the national surveys. For example, for boys aged 6 to 11, the percentage of those overweight in NHANES was 11%, whereas 20% of the Michigan primary care patients in this age group were overweight. In all groups, except for girls aged 6 to 11 years, prevalences of obesity of the primary care patients were greater than those of the Michigan schoolchildren in the KFYP survey.

Discussion

A larger than expected proportion of the children and adolescents in our primary care practices in Michigan are at risk for being overweight or are overweight. The prevalences of obesity in children and adolescents presenting for care in these practices are nearly 2 times greater than the national prevalences measured in NHANES II and NHANES III an d somewhat greater than a contemporary sample of Michigan schoolchildren. The absolute prevalences of obesity in the children and adolescents seen in our primary care practices were 3% to 9% higher than in the Michigan schoolchildren in all age-sex categories, except for girls aged 6 to 11 years.

It is not surprising that obesity is more prevalent in our sample than in the NHANES II and NHANES III surveys; NHANES data was gathered from 1976 to 1980 and 1988 to 1994, respectively, and obesity prevalences are steadily increasing. However, the reason that our patients are more obese than a contemporary sample of Michigan schoolchildren is unknown. The difference may be caused by systematic bias, as neither of the surveys was based on random sampling. However, in the analysis of our adult patients, the prevalence of obesity of patients was much greater than local community prevalences, even after adjusting for socioeconomic status and medical conditions known to be associated with obesity.⁸

The association between overweight and socio-economic status in children and adolescents is weak and not statistically significant.⁹ We speculate that obese children and adolescents have more physical and psychological complaints than healthy-weight individuals, causing them to visit their physicians more frequently. If they visit the practice more frequently, obese patients are more likely to be included in a survey of consecutive patients, thereby explaining the higher prevalences of obesity in primary care patients. Perhaps obese children or their parents are more worried about their health and therefore more likely to visit the physician for minor complaints. However, no association has been found between obesity and mental illness, although research regarding such an association is considered inconclusive at this time.¹⁰

Conclusions

The prevalences of obesity for children and adolescents presenting for care in Michigan primary care practices are higher than the state and national prevalences. Further studies using larger sample sizes, random sampling, and more settings are necessary to confirm or refute our findings. If this prevalence of obesity in primary care patients is confirmed, explanations for the differences should be explored.

Acknowledgments

We would like to thank the following people for their contributions to this study: Charles Kuntzelman, EdD, for providing us with the Michigan schoolchildren data; Nan Kreher, MEd, administration; Teresa Ettenhofer, administration and data analysis; and Kimber Gauthier, Jenny Folcik, and Celeste St. John, data entry. We would also like to thank the UPRNet and Michigan State University clinics that collected data. They are: Alpena Medical Arts, Alpena; Doctors Park Family Physicians, Escanaba; Dr Victoria Macki’s office, Newberry; OSF Medical Group, Gladstone and Escanaba; Gwinn Medical Center, Gwinn; Marquette Medical Clinic, Iron River; Burns Clinic, St Ignace; Alcona Health Center, Lincoln and Ossineke; East Jordan Family Health Center, East Jord an; Ewen Medical Clinic, Ewen; Northern Menominee Health Center, Spalding; Northern Michigan Health Services, Houghton Lake; Michigan State University-Family Practice at Clinical Center site, East Lansing; and Michigan State University-Family Practice at the Family Health Center, St. Lawrence Hospital, Lansing.