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Background: Nutrition counseling by physicians can improve patients' dietary behaviors and is affected by physicians' nutrition practices and attitudes, such as the perceived relevance of nutrition counseling. Objective: The objective was to provide data on medical students' perceived relevance of nutrition counseling, reported frequency of nutrition counseling, and frequency of fruit and vegetable intakes. Design: Students (n = 2316) at 16 US medical schools were surveyed and tracked at freshmen orientation, at the time of orientation to wards, and in their senior year. Results: Freshmen students were more likely (72%) to find nutrition counseling highly relevant than were students at the time of ward orientation (61%) or during their senior year (46%; P foi trend = 0.0003). Those intending to subspecialize had lower and declining perceptions of counseling relevance (P for trend = 0.0009), whereas the perceived relevance of counseling by primary care specialists remained high (P for trend = 0.5). Students were significantly more likely to find nutrition counseling highly relevant if they were female, consumed more fruit and vegetables, believed in primary prevention, had personal physicians who encouraged disease prevention, or intended to specialize in primary care. Only 19% of students believed that they had been extensively trained in nutrition counseling, and 17% of seniors reported that they frequently counseled their patients about nutrition. Students who consumed more fruit and vegetables, believed that they would be more credible if they ate a healthy diet, were not Asian or white, or intended to specialize in primary care counseled patients about nutrition more frequently. Medical students consumed an average of 3.0 fruit and vegetable servings/d, which declined over time. Conclusions: The perceived relevance of nutrition counseling by US medical students declined throughout medical school, and students infrequently counseled their patients about nutrition. Interventions may be warranted to improve the professional nutritional practices of medical students. KEY WORDS Medical students, diet, fruit and vegetable intakes, nutrition counseling, counseling correlates

Background: Laboratory-based investigations indicate that the consumption of foods with a low energy density (kcal/g) decreases energy intake. Although low-energy-dense diets are recommended for weight management, relations between energy density, energy intake, and weight status have not been clearly shown in free-living persons. Objectives: A representative US sample was used to determine whether dietary energy density is associated with energy intake, the weight of food consumed, and body weight and to explore the influence of food choices (fruit, vegetable, and fat consumption) on energy density and body weight. Design: A cross-sectional survey of adults (n = 7356) from the 1994-1996 Continuing Survey of Food Intakes by Individuals and two 24-h dietary recalls were used. Results: Men and women with a low-energy-dense diet had lower energy intakes ([approximately equal to] 425 and 275 kcal/d less, respectively) than did those with a high-energy-dense diet, even though they consumed more food ([approximately equal to] 400 and 300 g/d more, respectively). Normal-weight persons had diets with a lower energy density than did obese persons. Persons with a high fruit and vegetable intake had the lowest energy density values and the lowest obesity prevalence. Conclusions: Adults consuming a low-energy-dense diet are likely to consume more food (by weight) but to have a lower energy intake than do those consuming a higher-energy-dense diet. The energy density of a variety of dietary patterns, including higher-fat diets, can be lowered by adding fruit and vegetables, Our findings support the hypothesis that a relation exists between the consumption of an energy-dense diet and obesity and provide evidence of the importance of fruit and vegetable consumption for weight management. KEY WORDS Energy density, obesity, weight management, food patterns, fruit and vegetables, Continuing Survey of Food Intakes by Individuals, CSFII

Background: The biological variability in serum retinol concentrations has never been examined in a large sample, and its effect on population distribution estimates and the clinical assessment of vitamin A status is unknown. Objective: We evaluated the biological CV of serum retinol and examined the effect of the CV on both population distribution estimates and clinical assessments of vitamin A status by using data from the third National Health and Nutrition Examination Survey, 1988-1994. Design: We described the biological CV [(SD/[bar.x]) x 100] and examined associations between the CV and other factors via multivariate analysis of variance and linear regression. We used linear regression to predict the mean retinol concentration from a single concentration and established 95% CIs for each participant. We estimated the adjusted prevalence of inadequate vitamin A status (retinol < 1.05 [micro]mol/L) on the basis of the CIs. We estimated an uncertainty range for serum retinol concentrations for which the CIs included the established cutoff. Results: The mean biological CV across all strata was 6.45%. The biological CV varied significantly between racial-ethnic groups (P < 0.05). Prevalence estimates of inadequate serum retinol concentrations were reduced after adjustment for the total variation, with an adjusted overall prevalence of 0.62% compared with an unadjusted prevalence of 2.63%. Conclusions: The actual population prevalence of inadequate vitamin A status may be 75% lower than the estimates previously reported. Confirmation of vitamin A status may be needed for persons in the United States with observed serum retinol concentrations near the recognized cutoff. KEY WORDS Biological variation, CV, regression, regression to the mean, serum retinol, vitamin A, third National Health and Nutrition Examination Survey, NHANES III

Background: Between 1990 and 1993, fear of ethnic persecution led 83 000 ethnic Nepalese to flee from Bhutan to refugee camps in Nepal, where they remained at the time of this study. Reported cases of angular stomatitis (AS), ie, thinning or fissuring at the mouth angles, increased 6-fold from December 1998 to March 1999, from 5.5 to 35.6 cases per 1000 per month. This increase came after the removal of a fortified cereal from rations. Objectives: The main objectives were to assess the prevalence of AS and of low concentrations of riboflavin, folate, vitamin B- 12, and iron by using biochemical measures; to determine whether riboflavin status was associated with AS; and to assess the potential of AS as a screening measure for low riboflavin concentrations. Design: In October 1999, we performed a survey among a random sample of 463 adolescent refugees in which we conducted interviews and physical examinations and obtained blood specimens for riboflavin assessment. Riboflavin status was assessed with the erythrocyte glutathione reductase (EC 1.6.4.2) activity coefficient. After we excluded those adolescents who had taken vitamins during the past month, 369 were eligible for analyses. Results: AS was common (26.8%; 95% CI: 22.3, 31.3), the prevalence of low riboflavin concentrations was high (85.8%; 80.7, 90.9), and riboflavin status was associated with AS. Adolescents with AS had significantly lower riboflavin concentrations than did adolescents without AS (P = 0.02). The adjusted odds ratio for AS and low riboflavin concentrations was 5.1 (1.55, 16.5). Conclusion: Globally, riboflavin deficiency is rare. Its emergence in food-dependent populations can be a harbinger of other B-vitamin deficiencies. KEY WORDS Stomatitis, folic acid, Nepal, refugees, riboflavin, riboflavin deficiency

Background: The extent to which female physicians personally and clinically adhere to dietary recommendations is unknown and has implications for patients. Objectives: We aimed to identify US female physicians' personal and professional nutrition- and weight-related habits and to identify which, if any, of their personal habits predicted their clinical practices. Design: Our sample included the 4501 respondents to the Women Physicians' Health Study, a large, cross-sectional, questionnaire-based study of the health behaviors and counseling practices of US female physicians. Results: Forty-three percent of physicians performed nutrition counseling, and 50% performed weight counseling with patients at least yearly. Forty-six percent thought that discussing nutrition was highly relevant to their practices, 47% thought the same about discussing weight, and 21% stated that they had received extensive related training. Primary care physicians, obstetricians-gynecologists, pediatricians, vegetarians, and those with a personal history of obesity were more likely to provide nutrition and weight counseling to patients. Female physicians report regularly performing more nutrition and weight counseling than they do most other types of prevention-related counseling. Female physicians report relatively healthy diet-related habits, and these personal habits are related to their likelihood to counsel their patients about nutrition and weight. Conclusions: Nutrition and weight-related issues are important to female physicians in both their personal and professional lives, and these 2 spheres influence each other. KEY WORDS Physicians, women, diet, nutrition, body weight, obesity, counseling, eating disorders, Women Physicians' Health Study, female physicians

Background: Although body fat patterning has been related to adverse health outcomes in adults, its importance in children and adolescents is less certain. Objective: We examined the relation of circumference (waist and hip) and skinfold-thickness (subscapular and triceps) measurements to lipid and insulin concentrations among 2996 children and adolescents aged 5-17 y. Design: This was a community-based, cross-sectional study conducted in 1992-1994. Results: A central or abdominal distribution of body fat was related to adverse concentrations of triacylglycerol, LDL cholesterol, HDL cholesterol, and insulin; these associations were independent of race, sex, age, weight, and height. These associations were observed whether fat patterning was characterized by using 1) waist circumference alone (after adjustment for weight and height), 2) waist-to-hip ratio, or 3) principal components analysis. Compared with a child at the 10th percentile of waist circumference, a child at the 90th percentile was estimated to have, on average, higher concentrations of LDL cholesterol (0.17 mmol/L), triacylglycerol (0.11 mmol/L), and insulin (6 pmol/L) and lower concentrations of HDL cholesterol (-0.07 mmol/L). These differences, which were independent of weight and height, were significant at the 0.001 level and were consistent across race-sex groups. Conclusions: These findings emphasize the importance of obtaining information on body fat distribution, waist circumference in particular, in children. Waist circumference, which is relatively easy to measure, may help to identify children likely to have adverse concentrations of lipids and insulin. Am J Clin Nutr 1999;69:308-17. KEY WORDS Fat distribution, children, lipids, insulin, waist circumference, hip circumference, skinfold thickness, body weight, Bogalusa Heart Study