Correspondence

Social and Economic Consequences of Overweight in Adolescence

N Engl J Med 1994; 330:647March 3, 1994

Article

To the Editor:

Gortmaker et al. (Sept. 30 issue)1 found that obese young women were less likely to marry, had lower incomes, and had completed less schooling than nonobese women and that obese young men were less likely to marry than nonobese men. Two issues need further attention: the problem of stigmatization and the direction of causality.

The stigmatization of conditions ranging from obesity to AIDS is a serious social problem, one that the authors recognize as the main explanation for their findings. People who do not conform to social ideals of thinness suffer from discrimination that limits their access in education, employment, marriage, housing, and health care2. The current challenge is to decrease stigmatization and assist its victims.

Gortmaker et al. suggest extending disability laws to include coverage for obese persons. That addresses only entry into formal positions and does nothing for roles in private life, such as marriage. One alternative is to educate people to stop stigmatizing the obese. The editorial by Stunkard and Sorensen identifies physicians as a group that stigmatizes obese people,3 and educational programs for medical students have successfully reduced the stigmatization of obese patients4. Another approach is to help such people cope with stigmatization by recognizing it as a problem, readying themselves for stigmatizing acts, reacting adaptively to stigmatization, and repairing the damage to themselves and the system when such acts occur.

How socioeconomic status and obesity are related is not clear. Gortmaker et al. and Stunkard and Sorensen in their editorial reiterate the long-standing debate about social selection as compared with social causation. What is needed now is not an either-or approach, but rather an analysis of the conditions under which causality operates in either direction.

The young people studied by Gortmaker et al. were at a stage in life when they were attaining adult socioeconomic status. For young people, obesity may exert a strong influence on socioeconomic status. By contrast, most adults have largely attained their final educational, occupational, and marital status. For them, the values, types of behavior, and resources associated with their socioeconomic position influence their weight more strongly. Thus, obesity causes status and status causes obesity, each under different conditions of the life cycle5.

Jeffery Sobal, Ph.D., M.P.H.
Cornell University, Ithaca, NY 14853

5 References

1. 1

   Gortmaker SL, Must A, Perrin JM, Sobol AM, Dietz WH. Social and economic consequences of overweight in adolescence and young adulthood. N Engl J Med 1993;329:1008-1012
   Full Text | Web of Science | Medline

2. 2

   Sobal J. Obesity and nutritional sociology: a model for coping with the stigma of obesity. Clin Sociol Rev 1991;9:125-141
   

3. 3

   Stunkard AJ, Sorensen TIA. Obesity and socioeconomic status -- a complex relation. N Engl J Med 1993;329:1036-1037
   Full Text | Web of Science | Medline

4. 4

   Wiese HJ, Wilson JF, Jones RA, Neises M. Obesity stigma reduction in medical students. Int J Obes 1992;16:859-868
   Web of Science

5. 5

   Sobal J. Obesity and socioeconomic status: a framework for examining relationships between physical and social variables. Med Anthropol 1991;13:231-247
   CrossRef | Medline

Author/Editor Response

The authors reply:

To the Editor: Sobal correctly emphasizes the importance of stigma in the psychosocial disability associated with obesity. His own research has gone beyond the simple recognition of the stigma affecting obese persons to address the important task of helping them cope with it1. He imaginatively proposes that the direction of causality between obesity and socioeconomic status may change at different ages. However, his analysis ignores strong evidence that socioeconomic status in childhood influences the risk of obesity in adult life2,3. Furthermore, as we noted in our editorial, our understanding of the relation between obesity and socioeconomic status is not limited to two-way causality. There is now evidence of a genetic contribution to both obesity4 and socioeconomic status5.

Albert J. Stunkard, M.D.
University of Pennsylvania, Philadelphia, PA 19104

Thorkild I.A. Sorensen, M.D., Dr.Med.Sci.
Kommunehospitalet, 1399 Copenhagen K, Denmark

5 References

1. 1

   Sobal J. Obesity and nutritional sociology: a model for coping with the stigma of obesity. Clin Sociol Rev 1991;9:125-141
   

2. 2

   Stunkard AJ, Sorensen TIA. Obesity and socioeconomic status -- a complex relation. N Engl J Med 1993;329:1036-1037
   Full Text | Web of Science | Medline

3. 3

   Teasdale TW, Sorensen TIA, Stunkard AJ. Genetic and early environmental components in sociodemographic influences on adult body fatness. BMJ 1990;300:1615-1618
   CrossRef | Web of Science | Medline

4. 4

   Sorensen TI, Holst C, Stunkard AJ, Skovgaard LT. Correlations of body mass index of adult adoptees and their biological and adoptive relatives. Int J Obes 1992;16:227-236
   Web of Science

5. 5

   Teasdale TW. Familial influences in social class, educational level and intelligence. Malmo, Sweden: Liber Forlag Malmo, CWK Gllerup, 1985 (thesis).