The Journal of General Psychology, 2008, 135(4), 379392 Copyright 2008 Heldref Publications

Aging, Body Image, and Body Shape

F. RICHARD FERRARO JENNIFER J. MUEHLENKAMP ASHLEY PAINTNER KAYLA WASSON TRACY HAGER FALLON HOVERSON University of North Dakota

ABSTRACT. Participants were 25 older men (M age = 72 years, SD = 10 years) and 27 older women (M age = 71 years, SD = 8 years) who examined multiple line-drawing figures of babies, children, young adults, middle-aged adults, and older adults. Participants picked a number on a Likert-type scale ranging from 1 (very thin) to 9 (very obese) in response to questions including Which is the most attractive? and Which figure would you most like to look like? They also completed questionnaires about their body image and body shape. In response to the age-specific line drawings (e.g., those depicting older men and older women), older women endorsed thinner figures (e.g., picked smaller numbers) than did men. Likewise, older women reported thinking more about their body shape and appearance than did men and perceived their body image as a little too big in comparison with the older men who perceived their body image as just the right size. However, a breakdown of normal and overweight women in this sample revealed that for some overweight elderly women, obesity could become a satisfactory way of life. Much as with college-aged women, the endorsement of a thinner body image by many of the older adult female participants appeared to persist into late adulthood and suggests that research into body image issues with older adults is relevant and necessary. Keywords: aging, body image, body shape

THE ISSUE OF EATING DISORDERS and body image disturbances cooccurring has been a worldwide problem for decades (Gotesdam & Agras, 1995; Paxton, Neumark-Sztainer, Hannan, & Eisenberg, 2006; Smolak, 2006) Although the majority of research and treatment on eating disorders and their related problems have targeted young adults, little work has focused on understanding eating
Address correspondence to F. Richard Ferraro, Department of PsychologyUniversity of North Dakota, Corwin-Larimore Rm. 215, 319 Harvard St. Stop 8380, Grand Forks, ND 58202-8380, USA; f_ferraro@und.nodak.edu (e-mail).
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disorders and body image disturbances as they occur within an aging population an important circumstance that deserves researchers consideration from several perspectives. First, the aging population (age 65+) is one of the fastest growing segments in the United States and the world. Second, the aged are often overlooked when individuals consider eating disorders, and a bias may exist for which only young adults are considered to have eating and body image disorders. Only a few researchers have examined body image issues across the life span (Franzoi & Koehler, 1998; Hetherington & Burnett, 1994; Hurd, 2000; Janelli, 1993; Lerner & Jovanovic, 1990; Lewis & Cachelin, 2001). Excluding older adults from such research is troubling. Both men and women tend to put on weight in middle age, and that gain is inconsistent with societal emphases on being lean. However, some older adults experience lower weight during old age (Bennett & Stevens, 1996; Chrisler & Ghiz, 1993; DiGiovanna, 1994). It remains unclear how weight fluctuations across the life span influence the persistence of body image concerns into old age. Furthermore, other physical changes occur across the life span and into old age that can exacerbate body image issues (Tunaley, Walsh, & Nicolson, 1999; Whitbourne & Skultety, 2002). These changes include wrinkles, graying or thinning of hair, and decreased skin elasticity (Andres, 1989). Women may be more affected by such changes. Women in Western cultures tend to gain status and value through their appearance (Clarke, 2001, 2002). Thus, the perceived loss of beauty through the normal aging processes could increase older womens susceptibility to both body image disturbance and potential disordered eating (Robins, Trzesniewski, Tracy, Gosling, & Potter, 2002; Rodin, Silberstein, & Striegel-Moore, 1985; Webster & Tiggemann, 2003). The opposite is true for older men, who tend to gain status from issues related to intelligence, wealth, or power (Wilcox, 1997)not physical appearance. In other words, older men are stereotyped in more positive ways (e.g., as more intelligent), whereas older women are stereotyped in more negative ways. Such ageism remains commonplace in society and can negatively impact older women (McCuley, Marquez, Jerome, Blissmer, & Katula, 2002; Paxton & Phythian, 1999). Society may judge women, especially older women, more on their appearance than on any other attribute (Cohn & Adler, 1992; Crose, 2002; Demarest & Allen, 2000; Gupta & Schork, 1993; Wilcox, 1997), suggesting that physical appearance would be a salient concern throughout the life span. However, this view is not universal because berg and Tornstam (1999) found that among 2,002 Swedes, body dissatisfaction decreased with increasing age, for women in particular. Likewise, Anderson, Eyler, Galuska, Brown, and Brownson (2002) showed that advancing age was associated with body size satisfaction. Reboussin et al. (2000) reached a similar conclusion, finding positive associations for age and body satisfaction. Therefore, the research in this area is mixed and generally inconclusive. Although some early researchers have examined older adults and body image (Berscheid, Walster, & Bohrnstedt, 1973), many researchers have

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criticized these and other studies for relying on survey-based research methods. Despite the limitations of such studies, early results have indicated that older adults show evidence of body dissatisfaction. Several studies using figure line drawings have indicated that older women tend to show more body dissatisfaction than do older men (Fallon & Rozin, 1985; Rozin & Fallon, 1988). Other studies have examined this question across the life span (Allaz, Bernstein, Rouget, Archinard, & Morabia, 1998; Pliner, Chaiken, & Flett, 1990; Stevens & Tiggemann, 1998; Tiggemann & Lynch, 2001), concluding that body dissatisfaction for women is stable and tends to be higher than the dissatisfaction observed in older men (Berscheid et al., 1973; Lamb, Jackson, Cassidy, & Priest, 1993; Rozin & Fallon, 1988). These studies have underscored the importance of evaluating body image in the elderly, but their research designs have been limiting. Such studies need replication and extension. One valuable extension relates to the type of line drawings that studies use. In general, prior studies have used the same young adult figure line drawings across age groups. The use of young adult figures presents an inaccurate depiction of the elderly body, thus compromising the ecological validity of the figures endorsed by elderly persons. An important contribution of the present study is that we included line-drawing figures specific to the age group under investigation (i.e., the elderly). The inclusion of age-specific line drawings may result in a more accurate and valid assessment of body size and body image concerns. Furthermore, studies investigating body dissatisfaction with age-consistent line drawings (e.g., Rand & Wright, 2000) have tested only middle-aged adults, whose average age was 45.9 years. The average age of our participants was 70 years, thus extending this line of research to older adults. The present study examined older mens and womens perceptions of and feelings toward their body shape and body image. Although the participants rated line drawings across the entire life span (e.g., babies, children, young adults, middle-aged adults, older adults), we were most interested in their performance on the old-age adult line drawings, and in the current study, we analyzed only responses to these drawings. We hypothesized that, relative to older men, women would endorse significantly smaller figures and report greater concern about their body image and body shape. Method Participants We drew potential participant names from local lists of retired faculty and community members. Potential participants were called and invited to participate. Participants were 25 older men (M = 72.2 years, SD = 9.6 years) and 27 older women (M = 71.2 years, SD = 8.1 years). All were White, reflecting the demographic composition of the region in which the study took place. Table 1

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TABLE 1. Mean, Standard Deviation, and Range Performance as a Function of Group Female (n = 27) Range M 71.19 14.56 2.70 2.74 28.51 1.85 2.90 59.04 2.16 1.02 30.63 33.37 3.81 3.80 3.94 3.96 5.17 4.31 3.78 8.05 2.84 0.72 2.12 7.54 3.29 0.40 9.28 0.80 0.76 9.53 10.47 0.80 0.92 0.79 0.71 1.40 0.67 0.81 5685 1220 24 07 18.345.3 012 2.423.83 3870 1.034.47 0.132.63 2057 2057 25 1.55 1.55 25 27.5 35 25 SD 5087 822 14 07 21.938.1 06 1.833.5 1470 12.68 1.382.63 2046 2043 35.5 36 36 35 27.5 36 36 Range F(1, 50) 0.17**** 8.80** 1.02**** 0.30**** 0.03**** 0.01**** 0.39**** 0.66**** 9.65** 13.03*** 1.47**** 1.06**** 6.09** 6.85** 2.59 1.43 0.02**** 0.12**** 5.87**

Male (n = 25) SD 9.58 3.98 0.87 2.10 3.98 1.86 0.44 14.10 0.43 0.75 7.88 6.74 0.60 0.65 0.70 0.59 1.08 0.71 0.74

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Variable

Age Education Health Medications BMI GDS-SF EDI-BDS WAIS-R V BSQ BIPS State anxiety Trait anxiety LDQ1 LDQ2 LDQ3 LDQ4 LDQ5 LDQ6 LDQ7

72.20 17.43 2.48 2.42 28.21 1.88 2.82 56.36 1.60 0.26 27.68 30.84 4.30 4.38 4.28 4.18 5.12 4.38 4.30

Note. BMI = Body Mass Index; GDS-SF = Geriatric Depression Scale-Short Form; EDI-BDS = Eating Disorder Inventory-Body Dissatisfaction Subscale; WAIS-R V = Wechsler Adult Intelligence Scale-Revised Vocabulary; BSQ = Body Shape Questionnaire; BIPS = Body Image Perception Scale; LDQ = line drawing question. *p < .05; **p < .01; ***p < .001; ****ns.

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contains demographic information for participants. We recorded no data on participation rate. Procedure On arriving at the research lab, all participants provided written and verbal informed consent. We asked participants to complete a packet of questionnaires assessing demographic data, body image and shape variables, and mood symptoms. Participants took approximately 30 min to complete the study. After completing the questionnaires, participants were thanked for their time and provided $10 for their efforts. The Institutional Review Board (IRB) affiliated with the University of North Dakota approved all procedures. Measures Background questionnaire. We developed a background questionnaire for the purpose of the present study and assessed age, sex, educational history, self-rated health (on a Likert-type scale ranging from 1 [excellent] to 5 [poor]), height, weight, and current medications. Geriatric Depression ScaleShort Form (GDS-SF; Brink et al., 1982). We used the GDS-SF, a 15-item scale evaluating symptoms of depression in elderly adults. Participants answered yes or no, and we obtained scores by summing the number of positively endorsed statements. Scores of 5 or higher indicated probable depression. The GDS-SF has demonstrated strong psychometric properties in the elderly population (Brink et al.). Eating Disorder InventoryBody Dissatisfaction Subscale (EDI-BDS; Garner, Olmstead, & Polivy, 1983). We used the EDI-BDS, a 12-item instrument in which participants rated statements (e.g., I think my stomach is too big) on a Likerttype scale ranging from 1 (never) to 6 (always). The EDI has extensive validity and reliability data supporting its use (Garner et al.). Wechsler Adult Intelligence ScaleRevised Vocabulary Subtest (WAIS-R; Wechsler, 1981). The WAIS-R is an estimate of adult verbal intelligence. We gave participants up to 35 words 1 word at a time and asked them to provide a short definition of each. Responses to each word were scored as 0, 1, or 2 on the basis of definitional guidelines in the test-scoring manual. Higher scores indicated more accurate definitions. Scores can range from 0 to 70, with higher scores indicating greater verbal intelligence. The WAIS-R vocabulary subtest has extensive psychometric data suggesting it is valid and reliable as an indicator of verbal intelligence across age groups (Wechsler).

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Body Shape Questionnaire (BSQ; Cooper, Taylor, Cooper, & Fairburn, 1986). We used the BSQ, a 34-item questionnaire that asks participants to read a series of questions (e.g., Has feeling bored made you bored about your shape?) related to how they have been feeling about their appearance during the previous 4 weeks. Participants rated each question on a Likert-type scale ranging from 1 (never) to 6 (always). We obtained scores by averaging the response values, with higher scores indicating greater body dissatisfaction. The BSQ displays adequate validity and reliability data (Cooper et al.). Body Image Perceptions Scale (BIPS). We developed the BIPS for the present study. We gave participants eight statements about various body parts (e.g., I think my stomach is . . .) that were answered on a Likert-type scale ranging from 3 (much too small) to 0 (just the right size) to 3 (much too big). We summed response values to obtain the total score. Higher scores indicated greater body dissatisfaction. StateTrait Anxiety Inventory (STAI; Speilberger, 1983). We used STAI to measure state and trait anxiety. Participants responded to 40 items (items 120 for state anxiety, items 2140 for trait anxiety) on a Likert-type scale ranging from 1 (not at all) to 4 (very much so). We summed the responses to generate a total score, with higher scores indicating higher levels of anxiety. The STAI demonstrates strong psychometric properties (Speilberger). Figure line drawings. We used the figure line drawings from Rand and Wright (2000) to assess participants perceived body size and dissatisfaction. The line drawings included male and female figures across five age categories (i.e., babies, children, young adults, middle-aged adults, and older adults; Collins, 1991; Sorenson, Stunkard, Teasdale, & Higgins, 1983). The babies category did not break the images down by gender. For each of the five age categories and for each gender, we presented a total of nine images with the numbers 19 underneath each image. These numbers ranged from 1 (very thin) to 9 (very obese). Thus, there was a total of 81 images (4 [age groups] 2 [gender] 9 [images] + 9 [images for babies]). Participants picked the number (19) that corresponded to the line drawing that they thought best answered the following seven questions for each age group and each gender: (a) What figure(s) corresponds to the ideal body size (most attractive)?; (b) Which figure(s) are socially acceptable (which look OK)?; (c) Which figure(s) are acceptable?; (d) Which figure(s) do you like best?; (e) For your age group, which figure(s) best represents your current body size?; (f) For your age group, which figure(s) do you feel men and women should be?; and (g) For your age group, which figure(s) would you like to be? Reliability of these figures with a middle-aged group was strong (estimated Cronbachs = .92; Rand & Wright). In the present study, we used only responses to the older age line drawings in our analyses because they were the most relevant to our hypotheses.

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Results There were no demographic differences between the older men and older women, all F(1, 50) < 1.47, all ps > .32 (see Table 1), except for education level. Older men had significantly more education than did older women. For this reason, we included education level as a covariate in the analyses of variance (ANOVAs). However, education level added no effect beyond the reported results. We used no other variables as covariates because they did not differ significantly between men and women. Table 1 also presents means, standard deviations, ranges, and F and p values for each analysis of the study. For line-drawing question data, three of the seven questions showed significant (ps < .02) group differences in which older women endorsed thinner line-drawing figures (i.e., picked a smaller number) than did older men: (Question 1) Which figure is the most attractive?; (Question 2) Which figure is most socially acceptable?; and (Question 7) Which figure would they like to be? None of the remaining line-drawing questions revealed group differences. On the BSQ, older women reported thinking more about their body shape than did men (p = .003). On the BIPS, older women (p = .001) also perceived their body image as a little too big, whereas older men perceived their body image as just the right size. Because the mean body mass index (BMI) for both male and female older participants fell within the overweight category (National Institutes of Health, 2008), the results may reflect a simple understanding of public health issues rather than a concern about body image. In other words, some of the older womens ratings could reflect their desire to be at a healthier weight and hence have a better body image. Although we could not evaluate whether health motivated the participants responses, we examined whether responses on the study variables differed by current weight status. To test this possibility, we divided our older adult groups into normal or overweight categories on the basis of BMI ranges established by the National Institutes of Health. Participants whose BMI was in the 024.9 range were classified as normal and those with BMIs greater than 25 were classified as overweight. For older women, this classification resulted in our considering 10 as normal and 17 as overweight (63%). For older men, 4 fell in the normal BMI range and 21 were overweight (84%). Analyses showed no significant differences between normal and overweight older men on any of the study variables (see Table 2). We were most interested in the performance of the older women because they showed significantly more body-related concerns in the aforementioned analyses. In contrast to the older males, the older women had several significant group (i.e., normal vs. overweight) differences. In comparison with the normal-weight women, overweight women (a) were taking more medications, F(1, 25) = 9.79, p < .01; (b) had higher BMIs, F(1, 25) = 35.17, p < .01; (c) had higher BSQ scores, F(1, 25) = 8.42, p < .01; (d) had higher BIPS scores, F(1, 25) = 25.48, p < .01; and (e) endorsed

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TABLE 2. Mean and Standard Deviation Performance as a Function of Group for Normal Weight and Overweight Older Women Overweight (n = 17) M 70.82 14.47 2.88 3.59 32.85 2.65 2.85 60.53 2.46 1.42 31.53 34.00 3.79 3.65 3.94 3.94 5.94 4.53 4.00 7.40 2.62 0.78 2.12 6.01 3.95 0.39 8.17 0.82 0.63 11.12 12.21 0.81 1.06 0.90 0.83 0.98 0.62 0.81 0.09**** 0.11**** 3.01**** 9.79** 35.17** 2.88**** 0.63**** 1.20**** 8.42** 25.48** 0.40**** 0.16**** 0.81**** 1.21**** 0.001**** 0.04**** 29.33** 5.59* 3.80**** SD F(1, 25)

Normal Weight (n = 10) SD 9.45 3.20 0.52 1.16 1.99 0.53 0.41 10.91 0.43 0.36 6.21 7.06 0.50 0.60 0.60 0.47 0.94 0.60 0.70

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Variable

Age Education Health Medications BMI GDS-SF EDI-BDS WAIS-R V BSQ BIPS State anxiety Trait anxiety LDQ1 LDQ2 LDQ3 LDQ4 LDQ5 LDQ6 LDQ7

71.80 14.85 2.40 1.30 21.13 0.50 2.98 56.50 1.65 0.33 29.10 32.30 4.05 4.05 3.95 4.00 3.85 3.95 3.40

Note. BMI = Body Mass Index; GDS-SF = Geriatric Depression ScaleShort Form; EDI-BDS = Eating Disorder InventoryBody Dissatisfaction Subscale; WAIS-R V = Wechsler Adult Intelligence ScaleRevised Vocabulary; BSQ = Body Shape Questionnaire; BIPS = Body Image Perception Scale; LDQ = line drawing question. *p < .05; **p < .01; ***p < .001; ****ns.

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a larger line drawing on the question for your age group, which figure best represents your current body size? F(1, 25) = 29.33, p < .01. Furthermore, the overweight women also endorsed a larger line drawing on the question for your age group, which figure do you feel men and women should be? F(1, 25) = 5.59, p < .03 (see Table 3). Discussion The present results support our hypotheses that older women evidence greater concerns regarding body shape than do older men, although only 63% of the women in our sample were overweight, compared with 84% of the men. The present results showed that, as with younger women (e.g., Demarest & Allen, 2000; Franzoi & Koehler, 1998), older women were significantly more likely than older men to prefer and identify thinner line-drawing figures (i.e., pick a smaller number) as attractive and socially acceptable. In addition, older women, as compared with older men, selected significantly thinner line-drawing figures (i.e., picked a smaller number) as the shape that they would like to have. These findings are consistent with previous research (e.g., Rozin & Fallon, 1988) and highlight that preferences for thin bodies are prevalent among older adults, particularly older women. The fact that older women picked thinner line-drawing figures as more socially acceptable and attractive also indicates the pervasive impact of the Western cultural emphasis on a small or thin body shape and size. As discussed previously, older women face a number of physical changes that are part of the normal aging process but contradict societal definitions of thinness and beauty (Andres, 1989; Crose, 2002). Older women may be more vulnerable to increased body shape concerns as they age, and this vulnerability may negatively affect their self-worth (Shaw, Ebbeck, & Snow, 2000). The present results support the notion that older women remain susceptible to societal messages that thinness is the gold standard, particularly for female beauty. Further, supporting the notion that pressures toward thinness may influence older women, the older women in our study scored as significantly more concerned with their bodies than did the older men. In addition, older women, relative to older men, reported spending significantly more time in thinking about their body shape and were more likely to endorse a desire for a thinner body shape. These results underscore the salience of body image for older women and reinforce previous findings of body image as a pervasive lifetime concern (e.g., Tiggemann & Lynch, 2001), particularly for women. Body image concerns of older women and men could affect other psychological and physical health conditions. Awareness of these issues could enhance health care for the elderly. Also, the present findings could reflect the Centers for Disease Control and Preventions (2006) recent revelation of the obesity crisis as the leading health crisis in the United States. Concerns about weight-related problems, particularly among the elderly who experience many obesity-related health issues (e.g., heart

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TABLE 3. Mean and Standard Deviation Performance as a Function of Group for Normal Weight and Overweight Older Men Overweight (n = 21) M 71.29 17.57 2.57 2.52 28.30 2.14 2.77 56.29 1.59 0.29 27.81 31.38 4.31 4.40 4.31 4.21 5.10 4.43 4.31 9.90 4.12 0.93 2.18 3.43 1.90 0.44 15.25 0.37 0.80 8.11 6.27 0.56 0.66 0.77 0.64 1.17 0.76 0.78 SD F(1, 23) 1.21**** 0.01**** 1.47**** 1.23**** 0.06**** 2.84**** 2.40**** 0.003**** 0.06**** 0.15**** 0.27**** 0.84**** 0.03**** 0.18**** 0.22**** 0.43**** 0.07**** 0.60**** 0.02****

Normal Weight (n = 4) SD 6.68 3.20 0.00 1.50 6.96 0.58 0.26 6.29 0.73 0.43 8.39 9.38 0.87 0.65 0.25 0.00 0.50 0.25 0.50

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Variable

Age Education Health Medications BMI GDS-SF EDI-BDS WAIS-R V BSQ BIPS State anxiety Trait anxiety LDQ1 LDQ2 LDQ3 LDQ4 LDQ5 LDQ6 LDQ7

77.00 17.38 2.00 1.25 27.78 0.50 3.13 56.75 1.65 0.13 25.50 28.00 4.25 4.25 4.13 4.00 5.25 4.13 4.25

Note. BMI = Body Mass Index; GDS-SF = Geriatric Depression ScaleShort Form; EDI-BDS = Eating Disorder InventoryBody Dissatisfaction Subscale; WAIS-R V = Wechsler Adult Intelligence ScaleRevised Vocabulary; BSQ = Body Shape Questionnaire; BIPS = Body Image Perception Scale; LDQ = line drawing question. ****ns.

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disease, diabetes), may to some extent drive the endorsement of a thinner physique as the preferred body type for this age group. Thus, our findings not only indicate a preference for a smaller body shape but also may reflect heightened awareness of weight-related health concerns. To further understand this phenomenon, we analyzed the data by weight classification. Overweight older women differed significantly from normal-weight older women on a number of behavioral measures related to body shape, body image, and line-drawing endorsements. Overweight women were significantly more concerned with their bodies than were normal-weight women. This finding suggests that for older women, body image concerns may reflect acknowledgment of weight-related health issues among overweight older men and women rather than distortion of body image among those of normal weight. It may be erroneous to merely associate these body image issues with societal pressures to be youthful because of the recent national emphases on weight-related health issues. In addition, among men (84% of whom were overweight) no significant differences were noted on the body shape measures, suggesting a lack of concern for weight-related health and societal standards of body image. Thus, perhaps societal messages and pressures regarding weight, body shape, and weight-related health issues have a greater impact on women than on men. An alternative interpretation of our results may be that some older women accept their overweight status as a satisfactory lifestyle. This conclusion is suggested by the finding that, in comparison with normal-weight older women, overweight older women endorsed a larger line-drawing figure as ideal. However, researchers should also note that this endorsement may not always occur, because in the present sample, the overweight women produced higher scores on both the BSQ and the BIPS. These higher scores indicate that some body concerns and body shape preoccupation remain even among those who endorse a heavier ideal figure. Although overweight womens endorsement of a figure that was larger than the normal-weight womens ideal figure could mean that overweight older women are more comfortable with a larger figure, that endorsement could also reflect a desire to endorse as ideal any image that seems achievable, as opposed to one that seems better but unfeasible. Although the present study offers an important replication and extension of previous work, researchers must consider some limitations. First, the sample is one of convenience and is homogenous with respect to race, ethnicity, and socioeconomic status, and that circumstance limits generalizability. Second, all of the data were by self-report and subject to interpretation biases. In addition, the results represent a cross-sectional analysis of differences so that causality and temporal changes in body image across the life span are unidentifiable. In conclusion, the results of this study emphasize the need for research on body image and body shape beyond adolescence and middle age. The lack of differences for men but significant differences between men and women as well as between overweight and normal-weight older women continue to highlight that weight,

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body size, and body image are prominent concerns for older adult females. As with samples of college-aged women, the endorsement of a thinner body image and subsequent body concerns exist with samples of elderly people (especially older women), suggesting that research on body image issues of older adults is relevant and necessary.
AUTHOR NOTES
F. Richard Ferraro is a Chester Fritz Distinguished Professor in the Psychology Department at the University of North Dakota, where he has been since 1992. His interests include aging, cognition, gerontology, and eating disorders. Jennifer J. Muehlenkamp is an assistant professor in the Psychology Department at the University of North Dakota. Her interests include suicide, aging, and eating disorders. Ashley Paintner is a graduate student in the department of clinical psychology at Washington State University. Kayla Wasson is a doctoral student in the department of physical therapy at the University of North Dakotas School of Medicine and Health Sciences. Tracy Hager graduated from the University of North Dakota and works in the outdoor recreation field. Fallon Hoverson graduated from the University of North Dakota and is attending medical school at the universitys School of Medicine and Health Science.

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Manuscript submitted February 9, 2008 Revision accepted for publication April 28, 2008