Research of Note for July-August 2003

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Several studies of youth have made headlines in recent months, but the research may be more complicated than it seems at first glance. This month we look at the information behind the headlines about a study of the emotional damage of obesity, the surprising results of making condoms available in schools, and a less publicized study of violence among rural youth.

Obesity Hurts Quality of Life

Health-related Quality of Life of Severely Obese Children and Adolescents
Jeffrey Schwimmer, M.D; Tasha Burwinkle, M.A.; and James Varni, Ph.D.
Journal of the American Medical Association, Vol. 289, April 9, 2003, pgs. 1813-1819.
Available free while they last from Schwimmer at or University of California, 200 W. Arbor Dr., San Diego, CA 92103.

Obesity is in the news as a public health crisis, and this study shows that the emotional harm may be as bad as the physical harm. According to the children and their parents, the quality of life of obese children is comparable to that of children who receive chemotherapy for cancer.

Needless to say, children receiving chemotherapy have a much lower health-related quality of life, on average, than do healthy children.

Dr. Jeffrey Schwimmer and his colleagues asked 106 children and youths (ages 5 to 18) and their parents to fill out a survey asking about the child’s physical, emotional, social and school functioning. The youths had recently been referred to gastroenterology or nutrition clinics at Children’s Hospital and Health Center in San Diego.

Children’s health-related quality of life included their ability to move around and participate in sports, their levels of fear and sadness, the quality of their relationships with their peers, and how much they pay attention in school and do their school work. The study compared the scores of obese children with those for a sample of more than 8,000 healthy children and youth of the same age, and with 106 children who were receiving chemotherapy at two large children’s hospitals in San Diego and Los Angeles.

Previous studies report that children with cancer who are receiving chemotherapy have the lowest health-related quality of life compared with both healthy children and other children with serious health problems, such as juvenile rheumatoid arthritis and congenital heart disease.

When they compared the obese children with the healthy children and children receiving chemotherapy, the authors found:

• Obese youth missed an average of 4.2 days of school in the month before the survey, compared with less than a day for healthy children and youth.

• Obese children were more than five times as likely to have a significantly lower quality of life than the average for children of that age. The quality of life for 40 to 65 percent of obese children was impaired by health-related factors. These differences were found for all aspects of children’s lives, including their physical, emotional, social and school functioning.

• The parents of obese children reported that their children’s quality of life was lower than did the parents of healthy children. The parents of obese children even reported levels that were lower than those reported by the obese children themselves.

• Obese children were about as likely to have an impaired health-related quality of life as the children receiving chemotherapy for cancer.

Differences in the age, sex, race/ethnicity and socioeconomic status of healthy and obese children did not account for these findings.

The implications for the emotional health of obese children are staggering. However, since the study included very obese children, these findings may not be true for kids who are less obese. Because the study was conducted on children and youth in Southern California, its findings may not hold true for obese children in other parts of the country. For example, in areas where childhood obesity is especially common, such as Texas and Alabama, kids who are obese may have more friends and feel better about themselves.

Youth Violence in Rural Areas

Community Correlates of Rural Youth Violence
D. Wayne Osgood and Jeff M. Chambers.
Juvenile Justice Bulletin, U.S. Department of Labor,
May 2003.
Available free at, or contact Osgood with questions at, (814) 865-1304.

Just under half of the U.S. population lives in urban areas of 500,000 or more, but much of what we know about youth violence is based on those communities. Yet according to the U.S. Department of Commerce, about one in four Americans lives in a rural community with a population of 2,500 or fewer, and an additional 12 percent live in towns or cities with populations below 50,000.

This new study of rural youth violence found important similarities and one important difference in the community characteristics that predict youth violence. In the rural areas, as in urban areas, juvenile delinquency (as measured by the FBI’s Uniform Crime Report data) is more common in communities with higher levels of ethnic diversity, female-headed households and residential instability (proportion of families that moved from another dwelling in the previous five years). Ethnic diversity is measured by the likelihood that two randomly selected individuals would differ in ethnicity.

The researchers point out that ethnic diversity is linked to violence, not because of the number of members of minority groups, but because cultural differences in the community interfere with adults’ ability to work together in supervising their children. A 10 percent increase in ethnic diversity in this study is associated with 20-percent to 35-percent higher rates of youth violence.

The authors found that poverty was not related to youth violence in this study, although it is in studies of urban youth. The reason appears to be that poverty is related to residential stability, not instability, in rural areas. Apparently the low cost of housing and the help of families and friends enables poor rural families to stay in their homes. This inverse correlation between instability and rural poverty statistically cancels out the positive correlation between rural poverty and female-headed households and communities with ethnic diversity.

Another interesting finding is that arrest rates for youth violence were consistently lower in rural counties with the smallest populations. Per capita arrest rates increased as the size of the county increased, until the youth population reached about 4,000. Above that size, increases in the number of youth had little impact on arrest rates for violent crimes other than robbery.
This may be related to the sense in smaller communities that everyone knows who you are, so youth are less emboldened to commit violent crimes.

Although the authors don’t mention it, this finding has worrisome implications for the enormous public schools in many parts of the country, where a single school may have thousands of students.

The study is based on 264 counties in Florida, Georgia, Nebraska and South Carolina. Each county has a population between 560 and 98,000, and none includes a city with a population of 50,000 or more.

More Condoms, Less Sex?

Condom Availability Programs in Massachusetts High Schools: Relationships with Condom Use and Sexual Behavior
Susan Blake, Ph.D., Rebecca Ledsky, M.B.A., Carol Goodenow, Ph.D. and colleagues.
American Journal of Public Health, Vol. 93, June 2003, pgs. 955-961.
Available free from Blake at or George Washington University School of Public Health, 2175 K St. NW, Suite 700, Washington, DC 20037.

In results that surprised many advocates of sex education in schools, this study found that adolescents enrolled in schools where condoms were available were less likely to report having sexual intercourse than those in schools where they were not available. Less surprisingly, sexually active students in schools that made condoms available were twice as likely to use condoms, compared with students in other schools, but less likely to use other contraceptives.

Few public schools make condoms available; estimates range from 2 percent to 8 percent of high schools, with possibly as many as 42 percent of them in Massachusetts. The reason is that in 1990, the Massachusetts Board of Education adopted a policy urging high schools to consider making condoms available and offering instruction on proper condom use. Approximately 10 percent of Massachusetts districts with high schools approved condom availability programs.

This study examined whether the presence or absence of condom availability programs in Massachusetts high schools influenced adolescent sexual activity.

Condoms were available in five of the 48 randomly selected Massachusetts school districts, representing 15 percent of the high schools in those districts. Twenty percent of the youths attended schools with condom programs. Districts with or without condom programs did not differ in terms of population size, median family income, number of low-income families, suspension/drop-out rate or achievement scores. However, schools with condom programs included more African-Americans than did those without such programs (8 percent vs. 3 percent), more Asians (4 percent vs. 2 percent), more residents with bachelor’s degrees (35 percent vs. 23 percent) and more students whose primary language is not English (12 percent vs. 5 percent).

Condoms were distributed through school nurses and other personnel, such as gym teachers and assistant principals. The good news for students who wanted condoms was that parental consent was rarely required; the bad news for the students was that obtaining condoms usually required asking an adult who knew them, rather than putting money in a vending machine.

The results showed that students in schools with condoms available were more likely to have heard a presentation from a person with HIV/AIDS, to have received instruction about preventing HIV and to have been taught in school how to use a condom. These differences could have influenced the results.

Forty-nine percent of youths in schools without condom programs had ever had sexual intercourse, compared with 42 percent in the schools with condom programs. Thirty-five percent of students in schools without condom programs reported having sexual intercourse in the previous three months, compared with 30 percent in the schools with condom programs.

The average age at first intercourse did not vary, nor did the number of recent sexual partners or the youths’ perceptions of how difficult it was to obtain condoms. In fact, approximately 39 percent of students said they were likely to obtain condoms in school, whether the school had a condom program or not – suggesting that the students were able to get condoms from other students at school if they weren’t available through a school program.

Two-thirds of students in schools with condom programs reported having used a condom during their most recent sexual encounters, compared with only 52 percent of those in schools without a condom program. Although students in schools without condom programs were more likely to use other contraceptives (21 percent vs. 10 percent), that did not completely make up for the lower condom use.

However, some other contraceptives are more effective in preventing pregnancy. This probably explains why the pregnancy rates were not different in schools with or without condom programs. Differences in HIV rates were not evaluated.

Adolescents in schools with condom programs were less likely to have ever had sex or to have had sex recently, (during the past three months), whether or not they had condom instruction. However, the instruction is still important, because it probably increases the likelihood that the condom will be used effectively.

Do the results mean that making condoms available in schools decreases sexual activity? Not necessarily. The schools that made condoms available apparently did a better job of educating their students about HIV/AIDS. The parents were more highly educated. And there were other differences between the schools with and without condom programs that may have influenced the students’ sexual activity.

It is possible that making condoms available in schools reduces sexual activity by discouraging unprotected sex. For example, a girl might feel empowered to say no unless her boyfriend obtains condoms, and that might take a while since asking school personnel for condoms is probably embarrassing for many students.

Speculation aside, this study certainly suggests that making condoms available in school does not encourage students to have sex. The results also indicate that schools that actively educate students about the risks of sex, and which make condoms available and instruct youths about their use, are creating an atmosphere that reduces rather than encourages sexual intercourse.