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Social Marginalization of Overweight Children
Richard S. Strauss, MD; Harold A. Pollack, PhD Background: Overweight is the most common health
Results: Overweight adolescents were more likely to be
problem that faces children and adolescents. Although socially isolated and to be peripheral to social networks the correlation among overweight, low self-esteem, and than were normal-weight adolescents. Although over- depression is well known, social isolation among over- weight adolescents listed similar numbers of friends as weight children and adolescents has not been studied.
normal-weight adolescents, overweight adolescents re-ceived significantly fewer friendship nominations from Objective: To investigate social networks of over-
others than were received by normal-weight adoles- weight and normal-weight adolescents in a large, nation- cents (mean [SE] number of friendship nominations, 3.39 [0.08] vs 4.79 [0.04]; PϽ.001). Overweight adolescentswere also more likely to receive no friendship nomina- Design: Cross-sectional, nationally representative co-
tions than were normal-weight adolescents (odds ratio, 1.71; 95% confidence interval, 1.39-2.20). Decreased tele-vision viewing (PϽ.001), increased levels of sports par- Population: A total of 90 118 adolescents aged 13 to 18
ticipation (PϽ.001), and increased participation in school years who were enrolled in the National Longitudinal clubs (PϽ.001) were associated with significantly more Study of Adolescent Health, of which a 1:5 subsample friendship nominations and higher network centrality was selected for detailed in-home assessment, including scores among both overweight and normal-weight ado- height and weight measurements (n = 17 557). Over- weight was defined according to body mass index (Ͼ95thpercentile for age and sex).
Conclusions: Many overweight adolescents are so-
Main Outcome Measures: This analysis focuses on
cially marginalized. Such isolation may aggravate the so- the number of friendship nominations each adolescent cial and emotional consequences of overweight in this received from other adolescents. The number of friend- ship nominations and other social network measures werecalculated using statistical software.
Arch Pediatr Adolesc Med. 2003;157:746-752 There is no doubt that obesity is an undesirablestate of existence for a child. It is even moreundesirable for an adolescent, for whom evenmild degrees of overweight may act as a CHILDHOODOVERWEIGHTis
rapidly increasing.3 Withimportant exceptions, themost serious medical se- damaging barrier in a society obsessed with ever, the social and emotional aspects of The professional community is concerned with the medical concomitants of obesity, but the adolescent well-being, independent of their psychological and social perils are at least as important to those afflicted by the problem. The reason is clear; society does not tolerate excess weight. The effects of this overt and significant an impact on emotional devel- covert pressure to be thin can be powerful and Mayer7 observed that overweight girls of- ten have expectations of rejection and pro- (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157, AUG 2003 2003 American Medical Association. All rights reserved.
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gressive withdrawal. Many studies find that overweightadolescents have higher prevalence of depressive symp- Table 1. Demographic Data of Adolescents Enrolled in the
toms8 and lower self-esteem than are found among their National Longitudinal Study of Adolescent Health, 1994
normal-weight peers.9-11 However, other studies reportnormal levels of self-esteem.12,13 Differences in age, race, Normal Weight
Overweight
Demographic
(n = 15 705)
(n = 1852)
and income among studies may account for the discrep-ant findings. For instance, low self-esteem is not char- acteristic of obese, inner-city, African American chil- dren14 or obese preschool children.15 Analysis of the data from the National Longitudinal Survey of Youth indi- cates that early adolescence is a critical time for the de- velopment of low self-esteem in overweight children.16 Other data indirectly reflect the strong stigma as- sociated with overweight during childhood and adoles- cence.17 Studies of children as young as 6 years find that overweight individuals are likely to be described in de-rogatory terms.18,19 The studies performed by Richard-son et al20 in the 1960s indicated that overweight chil-dren are ranked by other children as the least-desirable schools were selected systematically, with selection probabili- friends. Childhood and adolescent overweight is associ- ties proportional to the school’s enrollment. Before sampling, ated with adverse social and economic status in subse- the schools were sorted by size, school type (public, paro- quent adulthood, with particularly strong effects re- chial, private), census region, level of urbanicity, and percent- ported among women. Gortmaker and colleagues21 found age of white students. Detailed sampling procedures are de- that adolescent girls who were overweight in 1981 had scribed elsewhere.25 All students who completed an in-school lower earnings, were less likely to be married, and were questionnaire (n=90118), plus those who did not complete the more likely to be in poverty than were otherwise com- questionnaire but were listed on the school roster, were eli- gible for 1:5 random selection for an in-home evaluation. These Friendship is an essential vehicle for the social and data include a broad range of information regarding family in-come, household composition, academic achievement, and the psychological development of adolescents.22-24 Given the presence of other health-related medical conditions.
importance of peer appearance norms, body image, and Complete demographic data were available for more than physical fitness to social and emotional development, 90% of the resulting sample. Special oversamples included Af- overweight may have lasting implications for child de- rican Americans and Hispanics and a subset of schools from velopment and adolescent well-being. Yet few studies pro- which all enrolled students were selected. Demographic de- vide concrete measures to scrutinize the social implica- tails of the cohort are shown in Table 1. The weighted in-
tions of overweight for individuals’ friendship ties and school (n = 90 118) and in-home (n = 20 762) samples approxi- mate a nationally representative, probability-based survey of To understand the extent that overweight adoles- cents may be isolated or socially marginalized in rela- OVERWEIGHT
tionships with school peers, we analyzed data from theNational Longitudinal Survey of Adolescent Health (Add Self-reported weight and height were obtained from the in- Health). We explored the social marginalization of over- home interview (n=17557: 2908 Hispanic, 3778 African Ameri- weight adolescents, as measured by the most detailed avail- can, 10 871 non-Hispanic white). Previous research has vali- able nationally representative data set, to explore social dated self-reported weights and heights as an indicator of connections among more than 20 000 high school stu- overweight in adolescents.26 Within this specific study, there dents for whom biometric data could be obtained.
was more than 95% concordance of overweight status using bothcalculated and measured weights and heights.27 Overweight wasdefined as a body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) greaterthan the 95th percentile for age and sex (n=1852) derived from the most recent Centers for Disease Control and Prevention Na-tional Center for Health Statistics growth curves.28 This defi- The study population consisted of 7th to 12th grade adoles- nition is in accordance with recommendations of the expert panel cents enrolled in wave 1 of Add Health. Add Health is a feder- ally funded study designed to assess the health status of ado-lescents and explore causes of health-related behaviors. A novel SOCIAL NETWORKS
feature of Add Health is the collection of detailed friendshipnetwork data. These data provide direct assessment of an in- A unique aspect of Add Health is the mapping of social net- dividual respondent’s social standing with her school peers. Re- works using data from all (responding) students who at- stricted data were obtained by arrangement with Add Health tended participating schools (n=90118). Each participating stu- after approval from the University of Medicine and Dentistry dent designated his or her 5 best male friends and 5 best female of New Jersey Institutional Review Board.
friends. This study design allows investigators to explore the The primary sample frame for Add Health was the Qual- interplay between individual characteristics and the social struc- ity Education Data database, which is thought to be the most ture of the school within which the student is enrolled. Add comprehensive list of high schools available. The sample high Health data include the identification number of students iden- (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157, AUG 2003 2003 American Medical Association. All rights reserved.
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Figure 1. Kamada-Kawai free energy drawing of a social network mapping for 1 of the 132 schools included in the analysis. Each dot in the figure represents a
National Longitudinal Study of Adolescent Health respondent. The size of the dots and the number next to each dot represent the number of friendship
nominations by others. The black dots represent overweight adolescents. As shown in the figure, overweight adolescents received less friendship nominations and
were less centrally located in the social network than normal-weight adolescents.
tified or “nominated” by the respondent as friends (out- cents that do not arise in self-reported out-degree measures degree measure). Using matrix programs (PAJEK, available on the Internet at http://vlado.fmf.uni-lj.si/pub/networks/pajek; andSAS IML, SAS Institute Inc, Cary, NC) the connections and re- SAMPLE BIAS
lationships between each student were determined (Figure 1).
Social network data were available for more than three quar-
The completeness of friendship nomination data and BMI data ters (77%) of adolescents with weight and height data. Figure differed across race/ethnic groups. However, these differences 1 demonstrates a social network of one of the schools with com- were small and not likely to influence outcome. Overall, friend- plete friendship data in the Add Health study.
ship nomination data were available for 77% of adolescents with For each adolescent, the number of friendship nomina- calculated BMI z scores (Hispanic, 74.6%; African American, tions from other students was identified (in-degree measure), as 80.2%; white, 76.3%). Similarly, although there were signifi- was the total number of friends and friends of friends (extended cant sex differences in those with (male, 48%) and without (male, network). The group of adolescents who received the most nomi- 51%) friendship data, these differences were also relatively small.
nations for friend and best friend were considered the most popu- There were no significant differences in BMI z scores or obe- lar. Reciprocity represented the likelihood that an individual who sity prevalence in those with and without friendship nomina- was nominated as best friend also returned the nomination.
tion data (mean [SE] BMI z score, 0.34 [0.02] vs 0.29 [0.03]; We also explore the centrality of Add Health respondents P = .83; obesity prevalence, 10.6% vs 9.6%; P = .23).
in their social networks, as captured by the Bonacich mea-sure.30,31 In brief, these centrality measures compare an indi- STATISTICAL ANALYSIS
vidual’s popularity to that of individuals with whom he or sheis connected. Individuals who have fewer friends than do oth- Friendship networks were generated using PAJEK and SAS IML ers in their friendship networks would have low centrality scores.
statistical software.34 Because the survey oversampled African We use centrality measure based on the in-degree social Americans and Hispanics, we used Add Health sample weights network. In-degree measures rely on friendship ties reported to provide prevalence estimates corresponding to a national rep- by others rather than those identified by self-report. Previous resentative sample as recommended.34 SEs were adjusted to ac- research identifies in-degree centrality as superior to out- count for school-wide clustering using Stata statistical soft- degree measures in obtaining accurate descriptions of friend- ware version 7.0 (Stata Corp, College Station, Tex). Differences ship and advice networks.32 In-degree measures are also de- in proportions were compared by the ␹2 test. Multivariate analy- signed to capture observed differences in social ties and sis, accounting for the weighted and stratified nature of Add reciprocity among unpopular, average, and popular adoles- Health, was used for continuous variables.
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Table 2. Friendship Network Scores for Normal-Weight
and Overweight Boys, National Longitudinal Study
of Adolescent Health, 1994
P
Variable
Overweight
Figure 2. Histogram of total number of friendship nominations (in-degree
measure) for overweight and normal-weight adolescents enrolled in the National Longitudinal Study of Adolescent Health. Overall, overweight children were more likely than normal-weight children to have 0 to 3 friendship nominations from other children (P normal-weight children were more likely to have 6 or more friendshipnominations compared with overweight children (PϽ.001).
Table 3. Friendship Network Scores for Normal-Weight
and Overweight Girls, National Longitudinal Study
of Adolescent Health, 1994
All measures of social relationships demonstrated that over-weight adolescents were more isolated and more periph- P
eral to social networks than were their normal-weight peers.
Variable
Overweight
Overweight adolescents were significantly less likely than normal-weight adolescents to be selected as friends (Figure 2, Table 2, and Table 3). The extended network
neighborhood of overweight adolescents included fewer friendsthanwasfoundfornormal-weightadolescents(Tables 2 and 3). Adolescents who nominated overweight peers as their friends tended to be less popular themselves; friends of overweight respondents received less friendship nomi- nations than did friends of normal-weight peers (mean [SE] number of nominations, 4.30 [0.10] vs 4.84 [0.09]; PϽ.001).
In addition, the number of friendship nominations was re- lated to overweight in a dose-dependent manner (mean [SE] number of nominations, 4.94 [0.15] for BMI Ͻ85th per-centile group; 3.97 [0.14] for BMI 85th-95th percentilegroup; 3.39 [0.15] for BMI Ͼ95thpercentilegroup;and3.12[0.15] for BMI Ͼ97th percentile).
ties pass through an individual also indicates that over- Overweight adolescents were less popular than their weight respondents are significantly less likely to play normal-weight peers when evaluated by other measures an “intermediary” role between well-connected adoles- of social ties. Overweight adolescents were significantly cents compared with normal-weight adolescents (P=.004).
less likely to receive 5 or more friendship nominations than Self-reported out-degree network measures ap- were normal-weight adolescents and were significantly less peared to overstate the social connectedness of over- likely to receive 2 or more best friend nominations (Tables weight adolescents, as reported by peers. Normal- 2 and 3). Overweight adolescents were significantly more weight respondents reported the same mean number of likely than normal-weight peers to receive no friendship friendship ties about others (4.58) as others reported about nominations (12% vs 7%; odds ratio, 1.71; 95% confi- them (4.79). Overweight respondents provided signifi- dence interval, 1.39-2.20). Adolescents nominated by over- cantly more nominations of others (4.29) than they re- weight respondents as best friends were less likely to re- ceived (3.39). Controlling for ethnicity, sex, parental edu- ciprocate the nomination than identified best friends of cation, family income, school size, and mean school normal-weight adolescents (Tables 2 and 3).
network density, overweight adolescents received fewer We found similar patterns using more global net- friendship nominations than did otherwise comparable work measures. Bonacich centrality scores, which mea- normal-weight peers who reported the same number of sure an adolescent’s connection to highly nominated peers, out-degree friendship ties (PϽ.001).
were significantly lower for overweight adolescents than We also examined race/ethnic variation in our main for normal-weight adolescents (Tables 2 and 3). The Free- results, with group-specific results provided for the 3 larg- man betweenness measure of the extent to which social est race/ethnic groups: Non-Hispanic white (non- (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157, AUG 2003 2003 American Medical Association. All rights reserved.
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Table 4. Friendship Network Score for Normal-Weight and Overweight Girls by Race/Ethnicity,
National Longitudinal Study of Adolescent Health, 1994*
Friendship Nominations by Others
Bonacich Centrality
Regression
Regression
Coefficient Associated
P
Coefficient Associated
P
Overweight
With Overweight
Overweight
With Overweight
*Data are presented as mean (SE). Multivariate analysis, controlling for family income, education, and marital status and school size and school-wide network density (number of actual nominations per school/number of possible nominations per school).
†Excludes individuals identified as both Hispanic and African American.
Table 5. Regression Coefficients Associated
With Overweight*
No. of Friendship
Nominations Received
(In-Degree Measure),
Mean (SE)
P
Dependent Variable
*Demographic factors include ethnicity, parental education, family income, and marital status; lifestyle factors, television and video viewing (hours), club Figure 3. Impact of television, video, and computer time (PϽ.001; weight
participation (number), sports participation (frequency); and school-wide status, PϽ.001; interaction, P=.73), sports participation (PϽ.001; weight network measures, adjusted for school-size and individual network density status, P = .006, interaction, P = .003), and number of nonsports clubs per school (number of actual nominations per school/number of possible (PϽ.001; weight status, P=.005; interaction, P=.42) on the number of friendship nominations received by overweight and normal-weightadolescents. In all cases, both main effects were independently correlatedwith the number of friendship nominations. Similar results are also obtained respondent who participated in sports 5 times per week nev- with network centrality scores (data not shown).
ertheless received approximately the same number of friend-ship nominations as a normal-weight adolescent who did Hispanic), African American, and Hispanic/Latino ado- lescents (Table 4). Within our stratified multivariate
Multivariate analysis also confirmed the relation- analysis, overweight respondents received significantly ship between overweight and decreased friendship nomi- fewer friendship nominations in 4 of the 6 examined sub- nations (Table 5). We found a robust association be-
groups, with the strongest results found among non- tween overweight and in-degree social ties. Our point Hispanic whites of both sexes and among young His- estimates were significant and stable across a range of panic men. Point estimates were notably smaller among specifications. In model 1, we examine unadjusted dif- African Americans than among non-Hispanic whites even ferences, finding a mean social penalty of 1.17 nomina- after controlling for confounding factors.
tions among boys and 1.61 among girls. In model 2, we Aside from overweight, several covariates were sig- control for standard sociodemographic factors and find nificantly associated with friendship nominations virtually identical point estimates among boys and de- (Figure 3). Decreased hours of television viewing
creased point estimates among girls.
(PϽ.001), increased levels of sports participation (PϽ.001), Because overweight might reflect sedentary life- and increased participation in school clubs (PϽ.001) were style factors associated with social marginalization, we associated with significantly more friendship nomina- control in model 3 for television watching, club partici- tions among both overweight and normal-weight adoles- pation, and sports. (Note that if overweight contributes cents. Although the effects of sports participation were stron- to increased sedentary activity, model 3 would, in prin- gest among normal-weight respondents, an overweight ciple, understate the impact of overweight on social ties.) (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157, AUG 2003 2003 American Medical Association. All rights reserved.
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As shown, inclusion of lifestyle factors had little impacton our results.
Table 6. Influence of Chronic Health Conditions
Schools may systematically differ in social network on Adolescent Friendship Networks*
characteristics based on school size (which alters possi-bilities for social connections), region, economic, or cul- Friendship
Nominations
Bonacich Network
tural factors. If such variation is correlated with over- (In-Degree Measure)
Centrality
weight prevalence, these patterns could produce aspurious correlation between overweight and social ties.
P
P
Medical Condition
Mean (SE)
Mean (SE)
To examine this possibility, we included school size andschool-specific network density as covariates in the same regressions. Inclusion of these effects had a negligible im- pact on our results for boys and led to slightly stronger estimated overweight effects among girls.
Finally, the relationship between overweight and de- creased friendship nominations was seen across almost all schools studied; overweight adolescents had fewer friendship nominations than did normal-weight adoles- cents in 108 (88.7%) of the 123 schools with availablefriendship network data. In addition, other chronic child- *The presence of asthma (12%) and migraine headaches (12%) was hood health conditions (eg, asthma, migraine head- assessed by parental report. Recurrent abdominal pain was defined as the aches, and chronic abdominal pain), in contrast to over- presence of abdominal pain or stomachache once a week or more by weight status, were not associated with decreased friendship nominations or with decreased network cen-
trality (Table 6).
women who participated in sports and club activities andwho spent fewer hours watching television displayed greater friendship attachments than their otherwise com-parable overweight peers.
Many overweight adolescent boys and girls are socially mar- We hypothesize that social marginalization of over- ginalized among their peers. Controlling for other fac- weight individuals contributes to reduced self-esteem and tors, overweight respondents received fewer friendship increased depressive symptoms among overweight ado- nominations than their normal-weight peers. Over- lescents. Previous studies have documented that adoles- weight respondents were less central to their social net- cent intimacy and friendships are important determi- works and had fewer friendship ties than others with whom nants of anxiety, depression, self-esteem, and overall they were connected. Overweight respondents were more mental health.19 Such patterns may also be especially im- likely to receive no friendship nominations than were their portant when viewed in light of widespread interest in normal-weight peers. The contrasts in friendship ties be- “social capital” and the growing literature highlighting tween overweight and normal-weight adolescents match the role of informal ties and “contact networks” in shap- overall patterns identified by others to distinguish popu- ing economic status,27 educational attainment,28 job seek- lar and unpopular children in social network data.23 ing,39 mental health,40 and general well-being.41 The di- Overall, the relationship between overweight and so- minished social capital available to overweight children cial isolation was moderate in strength; most over- and adolescents, captured by social network measures, weight respondents had at least one friendship nomina- may therefore contribute to the reduced social status and tion, and more than one-quarter had 5 or more friendship economic well-being of overweight adults.
nominations. Although the quality of friendships could From a methodologic perspective, the unique de- not be assessed, lower rates of reciprocity of best friend sign of Add Health allows scrutiny of social patterns that nominations among overweight respondents provide one would otherwise go undetected in analyses based solely suggestive indication that friendship ties involving over- on self-report. Self-reported friendship ties by over- weight adolescents significantly exceed the number of In addition to our main results, we found notewor- friendship ties to the same adolescents, as reported by oth- thy differences across the 6 race/ethnic and sex categories ers. The desire to provide socially desired responses pro- explored. Social marginalization of overweight children ap- vides one possible explanation for these discordant pat- pears most pronounced among non-Hispanic whites, with terns. The Add Health survey design may encourage the largest point estimates among young women. We found respondents to list 5 friends, even if the actual number of smaller effects among both African Americans and His- friends is greater or smaller than this number. Respon- panics, a result consistent with other research that sug- dents may also misperceive others’ views of friendship ties.
gests racial/ethnic differences in the emotional and social Cross-sectional studies such as this one also cannot consequences of overweight and obesity.12,35,36 unpack the causal direction of the linkage between over- Although overweight adolescents appear more so- weight and social ties. Both overweight and social margin- cially marginalized than other respondents, our multi- alization may be correlated with other, unmeasured vari- variate analysis suggests that increased participation in ables that play a strong causal role. Instrumental variable collective activities is associated with improved social ties.
methods may help to clarify these relationships.27 From a In every subgroup examined, overweight young men and clinical perspective, our results underscore that over- (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157, AUG 2003 2003 American Medical Association. All rights reserved.
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