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Social Status, Peer Influence, and Weight Gain in Adolescence: Promising Directions for Addressing the Obesity Epidemic

Social Status, Peer Influence, and Weight Gain in Adolescence: Promising Directions for... Since 1970, the prevalence of overweight has doubled among Americans, and the prevalence of obesity has quadrupled. As of 2003-2004, 32.2% of Americans (66 million people) were obese.1 The rates of overweight and obesity are growing even faster among adolescents than adults, particularly among girls. In just 6 years, between 1999 and 2004, the prevalence of overweight among girls aged 12 to 19 years increased from 14.0% to 18.2%. There was no change in obesity among women.2 The toll of overweight and obesity early in life is particularly harmful. Long-term health consequences include cardiovascular disease, diabetes mellitus, and sleep apnea, all of which carry increased medical costs.3 The penalties in terms of social status are particularly high for adolescents compared with adults. Overweight youth are often victimized, both physically and emotionally, by peers at school. Even when they are not explicitly bullied or mistreated, overweight youth—particularly girls—are at risk for being socially excluded. Such social exclusion has implications for depression, self-esteem, and disordered eating.4-7 But can the relationship work in the reverse? Can low social status lead to obesity? Lemeshow and colleagues8 provide evidence that lower social status can precede disproportionate weight gain. Probably since the first school opened in America, students have been establishing pecking orders of low- and high-status students, yet the obesity epidemic is relatively recent. How, then, can low social status in school be an important risk factor in this recent epidemic? An explanation for this apparent illogicality is that occupying a position at the bottom of the social, political, and economic ladder in society is now recognized as a fundamental cause of disease; the social ladder regulates access to the resources that produce and protect health, namely, the money, knowledge, and social connections that allow people to avoid risks for morbidity and mortality.9,10 When a new epidemic emerges, such as the obesity epidemic, low social status places people at higher risk. The contribution of the article by Lemeshow and colleagues8 is to show that subjective social status as well as the traditional objective measures of status—education and income—predict greater morbidity. If, indeed, low subjective social status is a fundamental cause of disease, direct prevention would require evening out inequalities of social status. It is human nature, however, to maximize differences and create a status hierarchy, and Lemeshow et al show that even small decrements in subjective social status are associated with increased weight gain. Lake Wobegon, where all the children are above average, will sadly remain trapped in the radio airwaves. Individual adolescents can improve their own social status through participation in different social activities, but the solution for the one, in this case, will not work for the many. More promising is to consider how low social status at school regulates exposure to norms and peer influence in the school's social hierarchy. Two examples illustrate this point. First, in a much-publicized recent study, Christakis and Fowler11 demonstrated that a person's chance of becoming obese increased by 57% if he or she had a friend who became obese during a prior interval. Because these results did not vary according to the geographic proximity of the friend, Christakis and Fowler concluded that the primary mechanism of influence is peer norms. To the extent that low-status girls are friends with other low-status girls, who also are more likely to be overweight,12 they may be more exposed to norms that promote weight gain. A second example is found in how the structure of peer networks can amplify the power of peer norms. Adolescents with delinquent friends are more likely to engage in delinquent behaviors themselves if their friendship network is closed (ie, their friends are friends with each other and few have friends outside the network).13 This same pattern may be true for norms regarding obesity. It makes sense that low-status girls would have smaller, more closed networks than higher-status girls, who presumably have greater choice of friends. A greater understanding of how peers influence health behaviors will help guide interventions in the future. Despite the need for urgent action in the obesity epidemic, the health community's mixed history of success with peer interventions should serve as a story of caution for designing interventions based on incomplete understandings of how adolescents' health behaviors are shaped by their peers. Some peer interventions can actually cause harm. For example, grouping together multiple at-risk youth to deliver some behavioral intervention can make things worse by creating a new peer culture organized around the very behaviors that the intervention was trying to change.14,15 Future adolescent health research, therefore, should seek to identity the specific ways that peers transmit health-related information and norms to each other in their everyday lives, either through face-to-face contact or through social networking activities on the Internet (eg, MySpace). The study by Lemeshow and colleagues8 contributes to this knowledge base, which in the future can be used to consistently harness the power of peers to promote health. Correspondence: Dr McNeely, Department of Population, Family, and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, 615 N Wolfe St, Suite E4546, Baltimore, MD 21205 (cmcneely@jhsph.edu). Author Contributions:Study concept and design: McNeely and Crosnoe. Drafting of the manuscript: McNeely. Critical revision of the manuscript for important intellectual content: McNeely and Crosnoe. Financial Disclosure: None reported. References 1. National Center for Health Statistics, Prevalence of overweight among children and adolescents: United States, 2003-2004. http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_child_03.htm. Accessed August 15, 2007 2. Ogden CLCarroll MDCurtin LRMcDowell MATabak CJFlegal KM Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006;295 (13) 1549- 1555PubMedGoogle ScholarCrossref 3. Dietz WH Health consequences of obesity in youth: childhood predictors of adult disease. pediatrics 1998;101 (3) ((pt 2)) 518- 525PubMedGoogle Scholar 4. Janssen ICraig WBoyce WFPickett W Associations between overweight and obesity with bullying behaviors in school-age children. pediatrics 2004;113 (5) 1187- 1193PubMedGoogle ScholarCrossref 5. Latner JDStunkard AJWilson GT Stigmatized students: age, sex, and ethnicity effects in the stigmatization of obesity. Obes Res 2005;13 (7) 1226- 1231PubMedGoogle ScholarCrossref 6. Strauss RSPollack HA Social marginalization of overweight children. Arch pediatr Adolesc Med 2003;157 (8) 746- 752PubMedGoogle ScholarCrossref 7. Needham BLCrosnoe R Overweight status and depressive symptoms during adolescence. J Adolesc Health 2005;36 (1) 48- 55PubMedGoogle ScholarCrossref 8. Lemeshow ARFisher LGoodman EKawachi IBerkey CSColditz GA Subjective social status in the school and change in adiposity in female adolescents: findings from a prospective cohort study. Arch pediatr Adolesc Med 2008;162 (1) 23- 28Google ScholarCrossref 9. Link BGPhelan J Social conditions as fundamental causes of disease. J Health Soc Behav 1995;spec no80- 94PubMedGoogle ScholarCrossref 10. Goodman ESlap GPHuang B The public health impact of socioeconomic status on adolescent depression and obesity. Am J Public Health 2003;93 (11) 1844- 1850PubMedGoogle ScholarCrossref 11. Christakis NAFowler JH The spread of obesity in a large social network over 32 years. N Engl J Med 2007;357 (4) 370- 379PubMedGoogle ScholarCrossref 12. Crosnoe RFrank KStrassmann Mueller A Gender, body size, and social relations in American high schools. Soc Forces In pressGoogle Scholar 13. Haynie DL Delinquent peers revisited: does network structure matter? AJS 2001;106 (4) 1013- 1057Google Scholar 14. Dishion TJDodge KA Peer contagion in interventions for children and adolescents: moving towards an understanding of the ecology and dynamics of change. J Abnorm Child Psychol 2005;33 (3) 395- 400PubMedGoogle ScholarCrossref 15. Dishion TJStormshak EA Child and adolescent intervention groups. Dishion TJStromshak EA Intervening in Children's Lives: An Ecological, Family-Centered Approach to Mental Health Care. Washington, DC American Psychological Association2007;Google Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Pediatrics & Adolescent Medicine American Medical Association

Social Status, Peer Influence, and Weight Gain in Adolescence: Promising Directions for Addressing the Obesity Epidemic

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Publisher
American Medical Association
Copyright
Copyright © 2008 American Medical Association. All Rights Reserved.
ISSN
1072-4710
eISSN
1538-3628
DOI
10.1001/archpediatrics.2007.23
Publisher site
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Abstract

Since 1970, the prevalence of overweight has doubled among Americans, and the prevalence of obesity has quadrupled. As of 2003-2004, 32.2% of Americans (66 million people) were obese.1 The rates of overweight and obesity are growing even faster among adolescents than adults, particularly among girls. In just 6 years, between 1999 and 2004, the prevalence of overweight among girls aged 12 to 19 years increased from 14.0% to 18.2%. There was no change in obesity among women.2 The toll of overweight and obesity early in life is particularly harmful. Long-term health consequences include cardiovascular disease, diabetes mellitus, and sleep apnea, all of which carry increased medical costs.3 The penalties in terms of social status are particularly high for adolescents compared with adults. Overweight youth are often victimized, both physically and emotionally, by peers at school. Even when they are not explicitly bullied or mistreated, overweight youth—particularly girls—are at risk for being socially excluded. Such social exclusion has implications for depression, self-esteem, and disordered eating.4-7 But can the relationship work in the reverse? Can low social status lead to obesity? Lemeshow and colleagues8 provide evidence that lower social status can precede disproportionate weight gain. Probably since the first school opened in America, students have been establishing pecking orders of low- and high-status students, yet the obesity epidemic is relatively recent. How, then, can low social status in school be an important risk factor in this recent epidemic? An explanation for this apparent illogicality is that occupying a position at the bottom of the social, political, and economic ladder in society is now recognized as a fundamental cause of disease; the social ladder regulates access to the resources that produce and protect health, namely, the money, knowledge, and social connections that allow people to avoid risks for morbidity and mortality.9,10 When a new epidemic emerges, such as the obesity epidemic, low social status places people at higher risk. The contribution of the article by Lemeshow and colleagues8 is to show that subjective social status as well as the traditional objective measures of status—education and income—predict greater morbidity. If, indeed, low subjective social status is a fundamental cause of disease, direct prevention would require evening out inequalities of social status. It is human nature, however, to maximize differences and create a status hierarchy, and Lemeshow et al show that even small decrements in subjective social status are associated with increased weight gain. Lake Wobegon, where all the children are above average, will sadly remain trapped in the radio airwaves. Individual adolescents can improve their own social status through participation in different social activities, but the solution for the one, in this case, will not work for the many. More promising is to consider how low social status at school regulates exposure to norms and peer influence in the school's social hierarchy. Two examples illustrate this point. First, in a much-publicized recent study, Christakis and Fowler11 demonstrated that a person's chance of becoming obese increased by 57% if he or she had a friend who became obese during a prior interval. Because these results did not vary according to the geographic proximity of the friend, Christakis and Fowler concluded that the primary mechanism of influence is peer norms. To the extent that low-status girls are friends with other low-status girls, who also are more likely to be overweight,12 they may be more exposed to norms that promote weight gain. A second example is found in how the structure of peer networks can amplify the power of peer norms. Adolescents with delinquent friends are more likely to engage in delinquent behaviors themselves if their friendship network is closed (ie, their friends are friends with each other and few have friends outside the network).13 This same pattern may be true for norms regarding obesity. It makes sense that low-status girls would have smaller, more closed networks than higher-status girls, who presumably have greater choice of friends. A greater understanding of how peers influence health behaviors will help guide interventions in the future. Despite the need for urgent action in the obesity epidemic, the health community's mixed history of success with peer interventions should serve as a story of caution for designing interventions based on incomplete understandings of how adolescents' health behaviors are shaped by their peers. Some peer interventions can actually cause harm. For example, grouping together multiple at-risk youth to deliver some behavioral intervention can make things worse by creating a new peer culture organized around the very behaviors that the intervention was trying to change.14,15 Future adolescent health research, therefore, should seek to identity the specific ways that peers transmit health-related information and norms to each other in their everyday lives, either through face-to-face contact or through social networking activities on the Internet (eg, MySpace). The study by Lemeshow and colleagues8 contributes to this knowledge base, which in the future can be used to consistently harness the power of peers to promote health. Correspondence: Dr McNeely, Department of Population, Family, and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, 615 N Wolfe St, Suite E4546, Baltimore, MD 21205 (cmcneely@jhsph.edu). Author Contributions:Study concept and design: McNeely and Crosnoe. Drafting of the manuscript: McNeely. Critical revision of the manuscript for important intellectual content: McNeely and Crosnoe. Financial Disclosure: None reported. References 1. National Center for Health Statistics, Prevalence of overweight among children and adolescents: United States, 2003-2004. http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_child_03.htm. Accessed August 15, 2007 2. Ogden CLCarroll MDCurtin LRMcDowell MATabak CJFlegal KM Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006;295 (13) 1549- 1555PubMedGoogle ScholarCrossref 3. Dietz WH Health consequences of obesity in youth: childhood predictors of adult disease. pediatrics 1998;101 (3) ((pt 2)) 518- 525PubMedGoogle Scholar 4. Janssen ICraig WBoyce WFPickett W Associations between overweight and obesity with bullying behaviors in school-age children. pediatrics 2004;113 (5) 1187- 1193PubMedGoogle ScholarCrossref 5. Latner JDStunkard AJWilson GT Stigmatized students: age, sex, and ethnicity effects in the stigmatization of obesity. Obes Res 2005;13 (7) 1226- 1231PubMedGoogle ScholarCrossref 6. Strauss RSPollack HA Social marginalization of overweight children. Arch pediatr Adolesc Med 2003;157 (8) 746- 752PubMedGoogle ScholarCrossref 7. Needham BLCrosnoe R Overweight status and depressive symptoms during adolescence. J Adolesc Health 2005;36 (1) 48- 55PubMedGoogle ScholarCrossref 8. Lemeshow ARFisher LGoodman EKawachi IBerkey CSColditz GA Subjective social status in the school and change in adiposity in female adolescents: findings from a prospective cohort study. Arch pediatr Adolesc Med 2008;162 (1) 23- 28Google ScholarCrossref 9. Link BGPhelan J Social conditions as fundamental causes of disease. J Health Soc Behav 1995;spec no80- 94PubMedGoogle ScholarCrossref 10. Goodman ESlap GPHuang B The public health impact of socioeconomic status on adolescent depression and obesity. Am J Public Health 2003;93 (11) 1844- 1850PubMedGoogle ScholarCrossref 11. Christakis NAFowler JH The spread of obesity in a large social network over 32 years. N Engl J Med 2007;357 (4) 370- 379PubMedGoogle ScholarCrossref 12. Crosnoe RFrank KStrassmann Mueller A Gender, body size, and social relations in American high schools. Soc Forces In pressGoogle Scholar 13. Haynie DL Delinquent peers revisited: does network structure matter? AJS 2001;106 (4) 1013- 1057Google Scholar 14. Dishion TJDodge KA Peer contagion in interventions for children and adolescents: moving towards an understanding of the ecology and dynamics of change. J Abnorm Child Psychol 2005;33 (3) 395- 400PubMedGoogle ScholarCrossref 15. Dishion TJStormshak EA Child and adolescent intervention groups. Dishion TJStromshak EA Intervening in Children's Lives: An Ecological, Family-Centered Approach to Mental Health Care. Washington, DC American Psychological Association2007;Google Scholar

Journal

Archives of Pediatrics & Adolescent MedicineAmerican Medical Association

Published: Jan 1, 2008

Keywords: obesity,adolescent,weight gain,epidemics,social status

References