Original Article Obesity

EPIDEMIOLOGY/GENETICS

The Influence of Social Relationships on

Obesity: Sex Differences in a Longitudinal
Study
Aldair J. Oliveira1, Mikael Rostila2, Antônio P. de Leon1 and Claudia S. Lopes1

Objective: To investigate the effect of five dimensions of social relationships on obesity and potential sex
differences in these associations.
Design and Methods: This study used longitudinal data from the Swedish Level of Living Surveys (LNU)
in 1991 and 2000. The sample included 3,586 individuals. The dimensions of social relationships
examined in this study include emotional support, frequency of visiting friends, marital status, marital
status changes, and a Social Relationships Index (SRI). Obesity status was based on BMI (kg/m2) and
calculated with self-reported measurements. The association between social relationships and the
incidence of obesity after 9 years of follow-up was evaluated through Poisson regressions.
Results: After controlling for confounders, we found that the lack of emotional support (RR ¼ 1.98; 95%
CI, 1.1-4.6) influenced the incidence of obesity among men. In addition, men with the lowest levels of
SRI (RR ¼ 2.22; 95% CI, 1.1-4.4) had an increased risk of being obese. Among women, SRI was not
significantly associated with obesity. Women who changed their marital status from married to unmarried
had lower risk of obesity (RR ¼ 0.39; 95% CI, 0.2-0.9).
Conclusions: This study provides evidence for the effect of social relationships on the incidence of
obesity, with significant differences by sex.

Obesity (2013) 21, 1540-1547. doi:10.1002/oby.20286

Introduction analysis with a large sample of respondents over a period of

The prevalence of overweight and obesity has reached epidemic pro-
portions in developed countries, and it is a growing problem in
developing countries (1). Numerous studies have investigated factors
that are related to overweight and obesity, showing associations
between BMI and various social demographic, behavioral, and psy-
chological factors, such as age (2), smoking cessation (3), and
depression (4), respectively.
Social relationships have been defined and measured in different
ways across various studies. Despite striking differences, two major
aspects of social relationships are consistently assessed: the degree
of integration in social networks and the degree of supportive social
interactions (i.e., having received social support). The first sub-
construct represents the structural aspects of social relationships,
whereas the latter signifies its functional aspects (5).
Studies showed that poor social relationships were associated
with increased risks for mortality (6,7) and other negative health
outcomes (8,9), including heart disease (10) and stroke (8). How-
ever, the evidence on whether social relationships influence obesity
is less robust. Christakis and Fowler (11) conducted a social network
32 years. The authors found that obesity may spread in social net-
works in a quantifiable and discernible pattern that depends on the
nature of the social ties (11). Additionally, another study suggested
that collective efficacy, which is measured as a combination of fac-
tors related to social cohesion and informal social control in a neigh-
borhood, was associated with overweight status among both children
and adolescents (12). Although the literature has provided some evi-
dence on the association between social relationships and obesity, it
is still unclear how different dimensions of these social relationships
contribute to obesity.
On the basis of assumption of the differential impact of distinct
dimensions of social relationships on the incidence of obesity, we
propose the following hypotheses. For emotional support, we
hypothesize that the psychological impact is the main explanation.
Low emotional support leads to negative psychological well-being,
which, in turn, could influence eating habits and dietary patterns
(13). Alternatively, the lack of emotional support can lead to stress.
Stressed individuals may change their eating behaviors by increasing
their food intake as a psychological response to higher stress levels
(14). The magnitude of social interaction, such as frequency of visit-
ing friends, could also influence BMI. Social control theory would

1
Department of Epidemiology, Institute of Social Medicine, Rio de Janeiro State University, Rio de Janeiro, RJ 20550-900, Brazil. Correspondence: Aldair J.
Oliveira (oliveira.jose.aldair@gmail.com) 2 Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institutet, Sweden

Disclosure: The authors declared no conflict of interest.

Received: 19 November 2012 Accepted: 20 November 2012 Published online 7 January 2013. doi:10.1002/oby.20286

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Original Article
EPIDEMIOLOGY/GENETICS
suggest that internalized obligations to—but mainly the overt influ-
ences of—network members tend to discourage poor health behav-
iors and encourage good ones (15). By this account, individuals who
do not regularly meet with friends have no social barriers to hinder
them from engaging in or maintaining poor eating, drinking, and
exercise habits, all of which contribute to obesity. A lack of contact
with friends could decrease exposure to social control, which pre-
vents people from adopting a healthy lifestyle that incorporates
moderate or vigorous physical activity and healthy food consump-
tion. In relation to marital status, our hypothesis is that nonmarried
persons have less social support that encourages healthy lifestyles
compared with their married counterparts, which could lead to obe-
sity. Moreover, nonmarried individuals are less likely exposed to
forms of informal social control over deviant health behaviors due
to the lack of a stable partner. Finally, poorer psychological well-
being and feelings of loneliness among the nonmarried could also
lead to poorer eating and exercise habits (16).
The role of social networks and social support on health is well
established in the literature, and studies have shown significant gen-
der differences in how social support operates in relation to health
(15,17-19). These studies have shown that contact with friends and
emotional support have more important consequences on women’s
than men’s health (20). Marriage, however, is more protective for
men than for women (21). Considering that women’s support net-
works often include close friends and relatives as confidantes,
whereas men typically name their wives as their main source of sup-
port, marital disruption appears to be more detrimental for men’s
health than for women’s health (22). In spite of the abundance of
research on gender differences in social capital and general health,
the literature on sex differences in the association between social sup-
port and the specific phenomenon of obesity is comparably scarce.
In general, our hypothesis is that poor social relationships influence
the risk of obesity among both women and men, although sex differen-
ces may exist depending on the dimension of social relationships.
Therefore, this study has two aims: (1) to examine whether there is an
association between different dimensions of social relationships (e.g.,
emotional support, frequency of visiting friends and marital status) and
the incidence of obesity, and (2) to investigate whether there are sex
differences in the influence of poor social relationships on obesity.
Methods and Procedures
Design and study population
The Swedish Level of Living Survey (LNU) is based on face-to-face
interviews with a representative sample of the Swedish population
aged 18-75 years. The survey has a panel design, but to maintain
the survey’s representativeness of the Swedish population at any
given time, each survey wave also includes younger generations and
newly arrived immigrants. Furthermore, the LNU allows different
approaches with the use of its data. This study uses a longitudinal
design, including 3,586 individuals who participated in both the
1991 and 2000 LNU waves in our analytical sample.
Measures
Obesity. The BMI (kg/m2) was calculated based on self-reported
measurements of weight and height. It was corrected with algo-
rithms by Nyholm and colleagues (23) using the Swedish popula-
www.obesityjournal.org
Obesity
tion to correct for self-reported bias because individuals tend to
underestimate their weights and overestimate their heights (24).
The following algorithms were adjusted for age and calculated sep-
arately by sex:
For men : BMIC ¼ 0:202 þ 1:005  BMISR þ 0:014  age
For women : BMIC ¼ 0:713 þ 1:023  BMISR þ 0:019  age
where BMISR is the value of the self-reported BMI, and age was in
years. BMIC is the new value of BMI. Aiming to assess the inci-
dence of obesity, a dichotomous variable was created based on LNU
2000 information, where individuals with BMI < 30 kg/m2 were
classified as nonobese and individuals with BMI  30.0 kg/m2 were
considered obese.
Social relationships. Considering that a single validated instru-
ment to evaluate the social relationships was not available in LNU,
we decided to the use three questions designed to cover different
dimensions of social relationships including emotional support, mari-
tal status, and the magnitude of social interaction, in order to study
associations with obesity. Additionally, the social relationship ques-
tions have been evaluated and results show good validity and reli-
ability (25).
Five different indicators of social relationships were evaluated based
on the following questions, where applicable. First, emotional support
is based on the question, Sometimes we need other people’s help and
support. Do you have a family member or friend who helps out if you
need to talk to someone about personal problems? The respondents
provided a dichotomous answer to these questions by answering
‘‘yes’’ or ‘‘no’’. Second, frequency of visiting friends is based on the
question, Do you engage in any of the following leisure activities
(e.g., visit friends and acquaintances)? The possible responses
include ‘‘yes, often,’’ ‘‘yes, sometimes,’’ and ‘‘no’’. All of the ques-
tions were asked in reference to the 12 months period prior to the
survey. The same questions appeared in both survey waves (i.e.,
1991 and 2000). Third, marital status is measured using three catego-
ries: ‘‘married/cohabiting,’’ ‘‘divorced/widowed,’’ and ‘‘single.’’ To
investigate potential modifications of social relationships on obesity,
we created two variables to represent changes in social relationships.
Fourth, changes in marital status between the two time points of our
study are captured using four categories: married in 1991 and in
2000, married in 1991 and not married in 2000, not married in 1991
and married in 2000, and not married in either 1991 or 2000. Finally,
we created a Social Relationships Index (SRI), aiming to investigate
changes in social relationships during the follow-up period, as a sum-
mary measure of two dimensions of social relationships, including
emotional support and frequency of visiting friends. For instance,
level 1 (the worst scenario) refers to individuals with poor emotional
support or low frequency of visiting friends at both survey waves
(i.e., 1991 and 2000); and level 4 (the best scenario) refers to individ-
uals with moderate to high levels of emotional support and high or
moderate frequency of visiting friends at both survey waves. Table 1
presents all of the possible combinations regarding the SRI
classification.
Covariates
The covariates that we included in the analysis were BMI in 1991, age,
marital status, social class, leisure-time physical activity, alcohol
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Obesity Social Relationships and Obesity Oliveira et al.

veys. In the first approach, exposure information provided by the

TABLE 1 All possible combinations of the variables that
LNU 1991 data was included as independent variables, and the
formed the SRI incidence of obesity (BMI  30 kg/m2 was the cut-off point for
the binary variable) in the LNU 2000 data was included as the out-
Frequency
come (i.e., the dependent variable). Subsequently, other models
Emotional of visiting
were adjusted using the two indicators, marital status changes and
support friendsa SRI SRI, which represent a combination of the LNU 1991 and 2000
data. In these models, marital status changes and SRI are the main
Possibilities 1991 2000 1991 2000 level
independent variables, and the incidence of obesity from the LNU
1 No No No No 1 2000 data is the focal dependent variable. Furthermore, prevalent
2 No No No Yes 1 cases of obesity (BMI  30) in the LNU 1991 data (6.9% among
3 No No Yes No 1 men and 6.8% among women) and individuals who did not partici-
4 No No Yes Yes 1 pate in both the 1991 and 2000 waves of LNU were excluded
5 No Yes Yes No 1 from the analysis to include only respondents with 9 years of fol-
low-up data. In addition to the main variables, other variables were
6 Yes No No Yes 1
included in the analysis to represent confounding scenarios in four
7 No Yes No No 1
different adjusted models that included the covariates. Model 1 was
8 Yes No No No 1 adjusted by age, BMI and social class (i.e., basic confounders).
9 Yes Yes No No 1 Models 2-4 added other variables to the previous model in a step-
10 Yes No Yes Yes 2 wise manner: Model 2 adds physical activity as a variable to the
11 Yes Yes Yes No 2 basic confounders in Model 1; Model 3 adds alcohol consumption
12 Yes No Yes No 2 to Model 2; and Model 4 (the fully adjusted model) adds smoking
13 No Yes No Yes 3 status to Model 3. To evaluate whether health behavioral variables
14 No Yes Yes Yes 3 act as possible mediators, these variables were included separately
15 Yes Yes No Yes 3 in Models 2-4. We also tested the multiplicity of interactions
16 Yes Yes Yes Yes 4 between the social relationship indicators and the health-related be-
havioral variables in predicting the incidence of obesity. All of the
models were fitted using the same modeling strategy, although for
a
Categories ‘‘yes, often’’ and ‘‘yes, sometimes’’ were allocated together as ‘‘yes.’’ the models that included the main independent variables in the
SRI, Social Relationships Index.
1991 and 2000 represent the measurement points when data were obtained in 1991 data, the covariates were also from the LNU 1991 data. For
Level of Living Survey. others models that include main independent variables from both
the LNU 1991 and 2000 data, the covariates were based on the
2000 data. In addition, linear models independent of BMI levels
were made, which included individuals who participated in both
consumption, and smoking. SEI was measured by means of the Swed- the LNU 1991 and 2000 survey waves, to investigate the influence
ish socioeconomic classification, which is based mainly on the status of social relationship changes on BMI.
and education needed for a certain occupation. The respondents in the
LNU are manually coded into different socioeconomic groups on the
basis of their present occupation and in line with the socioeconomic
classification from Statistics Sweden. The SEI is normally divided into
Statistical analysis
We calculated descriptive summary statistics by calculating the
seven categories: higher nonmanuals, medium nonmanuals, lower non-
means and standard deviations for the continuous variables and the
manuals, skilled workers, unskilled workers, farmers, and self-
frequencies for count variables. To estimate the relative risks (RR)
employed. We used a cruder categorization in our study including the
and their confidence intervals (95% CI), we ran the Poisson regres-
following classes: ‘‘nonmanual,’’ ‘‘manual,’’ and ‘‘self-employed/farm-
sion models using the sandwich estimator procedure (27). In addi-
ers’’ (26). Physical activity was measured with a question about how
tion, linear models were constructed using BMI from the LNU 2000
often the respondent practices any kind of exercise, outdoor activity or
data as the focal outcome and BMI from the 1991 data as one of
sport, with the following categorical responses: ‘‘yes, several times a
the explanatory variables. All statistical analyses were stratified by
week,’’ ‘‘yes, at least once a week,’’ ‘‘yes, 1-3 times a month,’’ ‘‘yes,
sex. The model parameters were estimated using R workspace ver-
but less often,’’ and ‘‘no, never.’’ Alcohol consumption was measured
sion 2.10.1.
with a binary response on whether the individual ever drinks wine,
beer, or liquor. Smoking was measured by classifying respondents in
three categories: ‘‘currently smoking,’’ ‘‘quit smoking,’’ or ‘‘never Results
smoked.’’ Among women, the mean age was 40 years old (standard deviation
of 13.2) in the LNU 1991 data, and the incidence of obesity (BMI
 30 kg/m2) was 8.0% in the 9-year follow-up. Among men, the
Modeling strategy mean age was also 40 years old (standard deviation of 8.5) in the
To examine whether dimensions of social relationships (e.g., emo- LNU 1991 data, and the incidence of obesity (BMI  30 kg/m2)
tional support, frequency of visiting friends, and marital status) and was 8.6% in the 9-year follow-up. A summary of the descriptive sta-
changes in social relationships (e.g., marital status changes and tistics for the other independent variables included in the models is
SRI) are associated with the incidence of obesity and modified by shown in Table 2, with the exception of marital status changes and
sex, we analyzed longitudinal data from the 1991 and 2000 sur- SRI, which are shown in Table 4.

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Original Article Obesity
EPIDEMIOLOGY/GENETICS

In the 9 year follow-up data, there were no significant associations
between the various dimensions of social relationships and the devel-
opment of obesity among women, with the exception of marital sta-
tus. Women who reported divorce or widowhood in the LNU 1991
data had a higher risk of obesity in the 2000 data compared with their
married or cohabiting counterparts (Model 4: RR ¼ 1.63; 95% CI,
1.1-2.6). In addition, there was some evidence, although not signifi-
cant, of an inverse relationship between individuals that reported a
low frequency of visiting friends (Model 4: RR ¼ 0.31; 95% CI, 0.1-
2.2) and the incidence of obesity among women. Contrarily, the
adjusted models presented in Table 3 showed a significant association
between poor emotional support (Model 4: RR ¼ 1.98; 95% CI, 1.1-
3.8) and the development of obesity among men. Furthermore, there
was some evidence that a low frequency of visiting friends (Model 4:
RR ¼ 1.81; 95% CI, 0.8-4.1) was associated with the risk of being
obese. In general, the models presented in Table 3 did not show sig-
nificantly different results across the various dimensions of social rela-
tionships. In addition, the multiplicity interaction tests between the
social relationships indicators and the health behavior variables in pre-
dicting obesity incidence were not significant. The only exception
was between marital status and smoking, where an interaction was
found between being single and having never smoked among women
in predicting a greater risk of obesity (RR ¼ 0.65; 95% CI, 0.4-0.9).
Regarding social relationships changes, Table 4 presents a signifi-
cant inverse association between women who were married in 1991

TABLE 2 Descriptive analysis of the independent variables included in the models

Number of observations  n (%)

LNU 1991a LNU 2000a

Variables Men Women Men Women

Emotional support
Yes 1 618 (95.7) 1 623 (98.2) 1 710 (94.4) 1 724 (97.1)
No 68 (4.3) 31 (1.8) 101 (5.6) 51 (2.9)
Frequency of visiting friends
Always 827 (47.9) 846 (50.8) 814 (44.9) 828 (46.6)
Sometimes 815 (49.4) 780 (47.5) 954 (52.7) 903 (50.9)
Never 44 (2.7) 28 (1.7) 43 (2.4) 44 (2.5)
Marital status
Single 466 (26.4) 322 (17.8) 282 (15.5) 183 (10.3)
Divorced or widower 71 (4.5) 141 (8.7) 138 (7.7) 254 (14.3)
Married or cohabited 1 149 (69.1) 1 191 (73.5) 1391 (76.8) 1 338 (75.4)
Social class
Manual 751 (44.1) 868 (51.3) 1 159 (45.6) 1 291 (52.9)
Non-manual 746 (44.3) 705 (43.8) 1 069 (42.3) 991 (41.2)
Self-employed/farmer 189 (11.6) 81 (4.9) 305 (12.1) 147 (5.9)
Physical activity
Yes, several times a week 752 (43.9) 783(46.7) 1 140 (43.9) 1 240 (50.0)
Yes, about once a week 395 (23.4) 453 (27.1) 556 (21.6) 590 (23.7)
Yes, 1–3 times a month 145 (8.7) 133 (8.1) 221 (8.6) 175 (7.0)
Yes, but less often 145 (8.6) 140 (8.6) 255 (10.0) 173 (7.1)
No, never 249 (15.2) 145 (9.5) 397 (15.9) 297 (12.2)
Alcohol consumption
Daily or almost daily 1 559 (92.7) 1 483 (89.6) 2 367 (91.8) 2 173 (87.8)
2–4 times a week 127 (7.3) 171 (10.4) 204 (8.2) 305 (12.2)
Once a week 1 559 (92.7) 1 483 (89.6) 2 367 (91.8) 2 173 (87.8)
2–3 times month 127 (7.3) 171 (10.4) 204 (8.2) 305 (12.2)
Less often or never 127 (7.3) 171 (10.4) 204 (8.2) 305 (12.2)
Smoking
Smoker 508 (29.5) 512 (29.6) 567 (22.0) 585 (23.9)
Quit smoking 415 (25.7) 367 (22.7) 779 (47.7) 633 (50.4)
Never smoked 763 (44.8) 775 (47.7) 1 225 (30.3) 1 260 (25.7)

mean (SD)
Means and standard deviations
BMI 24.1 (3.1) 23.2 (3.6) 26.1 (3.4) 25.3 (4.1)

a
The statistics presented are based on individuals who participated in both LNU waves (i.e., 1991 and 2000).

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Obesity Social Relationships and Obesity Oliveira et al.

TABLE 3 Relative risks (RR) and confidence intervals (CI 95%) of the association between social relationships and incidence
of obesity using Poisson regressions

Social Unadjusted Model 1 Model 2 Model 3 Model 4

relationships RR (95% CI) RR (95% CI) RR (95% CI) RR (95% CI) RR (95% CI)
Women (n ¼ 1654)
Emotional support
Yes 1.00 1.00 1.00 1.00 1.00
No 0.80 (0.2–3.1) 0.67 (0.2–2.4) 0.71 (0.2–2.5) 0.70 (0.2–2.5) 0.72 (0.2–2.5)
Frequency of visiting friends
Frequently 1.00 1.00 1.00 1.00 1.00
Sometimes 1.15 (0.8–1.6) 1.03 (0.7–1.5) 1.00 (0.7–1.4) 1.00 (0.7–1.4) 1.00 (0.7–1.4)
No 0.47 (0.1–3.3) 0.38 (0.1–2.7) 0.31 (0.1–2.2) 0.31 (0.1–2.2) 0.31 (0.1–2.2)
Marital status
Married or cohabited 1.00 1.00 1.00 1.00 1.00
Divorced or widower 1.71 (1.1–2.7) 1.59 (1.0–2.6) 1.61 (1.1–2.6) 1.61 (1.1–2.6) 1.63 (1.1–2.6)
Single 0.79 (0.5–1.2) 0.91 (0.6–1.5) 0.91 (0.6–1.5) 0.91 (0.5–1.5) 0.92 (0.6–1.5)

Men (n ¼ 1686)
Emotional support
Yes 1.00 1.00 1.00 1.00 1.00
No 2.14 (1.8–3.7) 1.95 (1.1–3.8) 2.02 (1.1–3.8) 2.01 (1.1–3.8) 1.98 (1.1–3.8)
Frequency of visiting friends
Frequently 1.00 1.00 1.00 1.00 1.00
Sometimes 0.89 (0.6–1.2) 0.93 (0.7–1.3) 0.93 (0.6–1.3) 0.92 (0.6–1.3) 0.93 (0.7–1.3)
No 2.05 (1.1–4.0) 1.68 (0.7–3.8) 1.81 (0.8–4.1) 1.80 (0.8–4.1) 1.81 (0.8–4.1)
Marital status
Married or cohabited 1.00 1.00 1.00 1.00 1.00
Divorced or widower 1.71 (1.1–2.8) 1.56 (0.9–2.9) 1.62 (0.9–3.1) 1.62 (0.9–3.1) 1.60 (0.8–3.0)
Single 0.79 (0.5–1.3) 0.80 (0.5–1.2) 0.82 (0.6–1.2) 0.82 (0.5–1.2) 0.81 (0.5–1.2)

The outcome was defined as a dummy variable representing two categories: nonobese (individuals that did not getting obese during the follow-up period the reference
group) and obesity (incidence cases in LNU 2000  BMI  30 kg/m2); exposures, the social relationships variables, and covariates were included based on LNU 1991 in-
formation. The Swedish Level of Living Survey (9 years of follow-up); Model 1: emotional isolation þ number of friends þ frequency of visiting friends þ marital status þ
age þ social class; Model 2: Model 1þ physical activity; Model 3: Model 2þ alcohol consumption; Model 4: Model 3þ smoking.

but changed their status to nonmarried in 2000 (Model 4: RR ¼ Discussion

0.39; 95% CI, 0.2-0.9) and the incidence of obesity. By contrast,
men who divorced had a higher, but not significantly, risk of
being obese (Model 4: RR ¼ 1.30; 95% CI, 0.7-2.3). Contrarily,
we find a direct association between men with the lowest levels
of SRI (level 1 vs. level 4  Model 4: RR ¼ 2.22; 95% CI,
1.1-4.4 / level 2 vs. level 4—Model 4: RR ¼ 1.93; 95% CI,
1.1-3.5) and the incidence of obesity. Among women, SRI was
not related to the incidence of obesity even at the lowest level
of SRI (Model 4: RR ¼ 1.01; 95% CI, 0.3-3.3). In general, the
models presented in Table 4 did not show different results
across the dimensions of the social relationships. Moreover,
Table 5 also showed a significant (p < 0.05) association for
women who were married in 1991 and changed their status to
nonmarried in 2000. In this sense, the fully adjusted multiple
linear model (Model 5) showed that women in this group
decreased their BMI by 0.54 units, on average, because of their
change in marital status between the two survey waves. On the
contrary, SRI results among men did not support the results pre-
sented in Table 4. Therefore, the multiple linear models showed
that the lowest levels of SRI were not significantly associated
with BMI.
This study examined both the structural and functional aspects
of social relationships in predicting obesity. Overall, our hypoth-
esis was that poor social relationships have a negative influence
on obesity. Moreover, we hypothesized that the association
between social relationships and obesity is moderated by sex,
depending on the social relationship dimension. Our results
largely confirmed that poor relationships predict a greater risk
of obesity, although some of our findings also suggested that
individuals with poor social relationships have a lower incidence
of obesity.
Focusing on our main results, the lack of emotional support is sig-
nificantly related to the increased incidence of obesity among men,
even after controlling for known confounders. The lack of emotional
support could influence obesity through psychological pathways
such as feelings of loneliness, lower self-esteem, and higher stress
(14,28,29). Such emotional states could exacerbate the likelihood of
food intake while depressing levels of physical activity, which in
turn, increase body weight. However, we found no significant effect
of emotional support on obesity among women.

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Original Article Obesity
EPIDEMIOLOGY/GENETICS

TABLE 4 Frequency, relative risks (RR) and confidence intervals (CI 95%) of the association between social relationships
changes and the incidence of obesity using Poisson regressionsa

Social relationships Unadjusted Model 1 Model 2 Model 3 Model 4

changes N (%) RR (95% CI) RR (95% CI) RR (95% CI) RR (95% CI) RR (95% CI)
Women (n ¼ 1654)
SRI
Level 4 1533 (8.0) 1.00 1.00 1.00 1.00 1.00
Level 3 65 (9.2) 1.52 (0.7–3.3) 0.95 (0.4–2.1) 0.80 (0.4–1.8) 0.80 (0.3–1.7) 0.81 (0.3–1.7)
Level 2 40 (2.5) 0.31 (0.1–2.1) 0.28 (0.1–0.9) 0.26 (0.1–1.8) 0.25 (0.1–0.8) 0.27 (0.1–0.8)
Level 1 17 (12.5) 1.55 (0.4–5.7) 1.19 (0.3–4.4) 1.16 (0.3–4.2) 0.99 (0.3–3.2) 1.01 (0.3–3.3)
Marital status changes
Marriage/marriage 1048 (8.5) 1.00 1.00 1.00 1.00 1.00
Marriage/non-marriage 143 (3.5) 0.41 (0.2–0.9) 0.38 (0.2–0.9) 0.38 (0.2–0.9) 0.37 (0.2–0.9) 0.39 (0.2–0.9)
non-marriage/marriage 208 (8.2) 0.96 (0.6–1.6) 1.28 (0.7–2.2) 1.29 (0.7–2.2) 1.30 (0.7–2.2) 1.30 (0.7–2.2)
Non-marriage/non- marriage 255 (8.6) 1.01 (0.6–1.5) 1.00 (0.6–1.5) 1.03 (0.6–1.6) 0.97(0.6–1.5) 1.00 (0.6–1.6)

Men (n ¼ 1686)
SRI
Level 4 1509 (8.2) 1.00 1.00 1.00 1.00 1.00
Level 3 80 (3.7) 0.46 (0.2–1.4) 0.46 (0.1–1.4) 0.44 (0.1–1.4) 0.45 (0.2–1.4) 0.45 (0.2–1.4)
Level 2 72 (16.4) 2.00 (1.1–3.6) 1.98 (1.1–3.6) 1.92 (1.1–3.5) 1.92 (1.1–3.5) 1.93 (1.1–3.5)
Level 1 36 (22.2) 2.70 (1.4–5.0) 2.34 (1.2–4.6) 2.19 (1.1–4.3) 2.20 (1.1–4.3) 2.22 (1.1–4.4)
Marital status changes
Marriage/marriage 1040 (7.9) 1.00 1.00 1.00 1.00 1.00
Marriage/non- marriage 109 (11.0) 1.37 (0.8–2.4) 1.24 (0.7–2.2) 1.29 (0.7–2.3) 1.29 (0.7–2.3) 1.30 (0.7–2.3)
Non-marriage/marriage 260 (6.1) 0.77 (0.5–1.3) 0.64 (0.4–1.1) 0.63 (0.4–1.1) 0.63 (0.4–1.1) 0.63 (0.4–1.1)
Non-marriage/non-marriage 277 (12.3) 1.54 (1.1–2.2) 1.24 (0.8–1.8) 1.25 (0.8–1.9) 1.26 (0.8–1.9) 1.26 (0.8–1.9)

a
The Poisson regressions were made using the sandwich estimator procedure; the outcome was defined as a dummy variable representing two categories: non-obese
(individuals that did not getting obese during the follow-up period—the reference group) and obesity (incidence cases in LNU 2000  BMI  30 kg/m2); exposures, the
social relationships variables, and covariates were included based on LNU 2000. The Swedish Level of Living Survey (9 years of follow-up) ; N(%) ¼ number of observa-
tions and percentage of obesity according to social relationships changes variables; SRI ¼ Social Relationships Index RR ¼ Relative Risk; CI ¼ confidence Interval; Model
1: social relationships changes þ marital status changes þ age þ social class þ BMI in 1991; Model 2: Model 1 þ physical activity ; Model 3: Model 2 þ alcohol con-
sumption ; Model 4: Model 3 þ smoking.

Furthermore, the frequency of visiting friends had an effect on obe-
sity status for both sexes, although in opposite directions. We found
a positive association between the frequency of visiting friends and
being obese among men, whereas the association was reversed
among women. These results could be explained by social control
theory, which states that the lack of a social network influences
health behaviors through low social control over deviant health
behaviors, such as low levels of physical activity and poor nutrition
(30). However, the factors for or against good health behaviors
depend on the characteristics of the social network. Given the sex
differences in our results, we postulate two possible explanations.
First, social contact with friends might be qualitatively different for
women and men in relation to how they influence health behavior.
Women’s social networks may not exclusively support good health
behaviors to the same extent as men’s networks. Second, even
women with poor social contacts are affected by other forms of
social control—namely the media—which enforce the high social
value of maintaining a slim body.
Marital status was associated with obesity among both men and
women. Those who reported that they had been divorced or wid-
owed had a higher risk of developing obesity compared to those
who reported that they remained married. An explanation for this
pattern could be the mutual social support and social control that
married couples usually experience, while divorced and widowed
individuals lose this type of support, which may lead to an unheal-
thy lifestyle (31). Furthermore, gender differences in how changes
in marital status affects obesity sheds some light on this issue. Only
women who became non-married (divorced or widowed) during the
follow-up period had a higher risk of being non-obese compared
with those who were married at both measurement points. This
result aligns with findings from another study (32) that showed a
significant association between becoming non-married and a BMI
decrease in a 2-year follow-up period among women. Although the
mechanisms linking marriage and obesity are not fully understood,
some studies have suggested that some relationships are more im-
portant than others (33,34).
According to the SRI that was used to summarize changes in social
relationships, the models confirmed gender differences. Among men,
levels of social relationships influenced the development of obesity.
The persistence of poor levels of social relationships across the sur-
vey waves had an even more detrimental impact on health. Our
results showed that primarily men who had poor social relationships
during the whole follow-up period (1991-2000) increased their like-
lihood of becoming obese. Contrarily, no effect was detected among

www.obesityjournal.org Obesity | VOLUME 21 | NUMBER 8 | AUGUST 2013 1545

Obesity Social Relationships and Obesity Oliveira et al.

TABLE 5 Regression coefficients and standard errors estimated from multiple linear regressions for the association between
social relationships changes and BMI in LNUa

Social relationships changes Model 1 b (SE) Model 2 b (SE) Model 3 b (SE) Model 4 b (SE) Model 5 b (SE)
Women (n ¼ 1654)
SRI
Level 4 – – – – –
Level 3 0.37 (0.28) 0.34 (0.28) 0.24 (0.28) 0.25 (0.28) 0.23 (0.29)
Level 2 0.34 (0.36) 0.32 (0.36) 0.34 (0.36) 0.34 (0.36) 0.32 (0.36)
Level 1 0.20 (0.57) 0.16 (0.57) 0.07 (0.58) 0.03 (0.56) 0.06 (0.56)
Marital status changes
Marriage/marriage – – – – –
Marriage/non-marriage 0.44 (0.20)b 0.46 (0.20)b 0.53 (0.20)b 0.55 (0.20)b 0.54(0.20)b
Non-marriage/marriage 0.45 (0.20)b 0.45 (0.21)b 0.19 (0.19) 0.18 (0.19) 0.20(0.19)
Non-marriage/non- marriage 0.11 (0.16) 0.12 (0.16) 0.21 (0.16) 0.23 (0.16) 0.22(0.16)

Men (n ¼ 1686)
SRI
Level 4 – – – – –
Level 3 0.38 (0.21)c 0.37 (0.21)c 0.38 (0.21) 0.38 (0.21)c 0.36 (0.21)c
Level 2 0.41 (0.23)c 0.42 (0.23)c 0.43 (0.23) 0.43 (0.23)c 0.41 (0.23)c
Level 1 0.22 (0.31) 0.13 (0.14) 0.23 (0.32) 0.23 (0.32) 0.22 (0.32)
Marital status changes
Marriage/marriage – – – – –
Marriage/non-marriage 0.22 (0.18) 0.23 (0.18) 0.21 (0.18) 0.21 (0.18) 0.17 (0.18)
Non-marriage/marriage 0.24 (0.15) 0.23 (0.15) 0.24 (0.14)c 0.24 (0.14)c 0.22 (0.15)
Non-marriage/non-marriage 0.10 (0.13) 0.13 (0.13) 0.14 (0.13) 0.14 (0.13) 0.19 (0.13)

The linear regressions were made using the BMI in LNU 1991 as an explanatory variable and the continuous explanatory variable (age) center led in the mean; the out-
come was the BMI (kg/m2) in LNU 2000. The covariates were included based on informations provided by LNU 2000. The Swedish Level of Living Survey (9 years of fol-
low-up)
SRI ¼ Social Relationships Index
a
p < 0.001;
b
p < 0.05;
c
p < 0.10 n ¼ number of observations; b ¼ coefficient estimated; SE ¼ estimation error.Model 1: BMI in 1991þsocial relationships index þ marital status changes þ age;
Model 2: Model 1 þ social class; Model 3: Model 2 þ leisure-time physical activity ; Model 4: Model 3 þ alcohol consumption; Model 5: Model 4 þ smoke status.

women, although they are generally more likely to seek and receive
emotional support from their social networks in comparison to men.
Women also have a larger dependence on social networks (5). Ini-
tially, these results may seem contradictory. However, we draw
upon alternative explanations for why social relationships contribute
to lower obesity rates among women (35). One of the key themes
underlying this assumption may be the differential standards of body
image for women versus men. Various authors, working within both
feminist and broader sociocultural paradigms, have suggested that
women in Western societies are constantly faced with sociocultural
ideals of slimness that are spread through social networks. Such
pressures might lead to dissatisfaction with the body, dietary
restraints (36), and eating disorders (37) that inadvertently lead to
higher risks of obesity.
Our results need to be interpreted in the context of six potential
methodological limitations. The first involves the use of five differ-
ent indicators of social relationships. These are based on single
questions with limited response alternatives, instead of the use of a
validated instrument which could take several dimensions of social
relationships into account at the same time. However, this approach
was helpful in disentangling the various potential mechanisms and
to scrutinizing how different dimensions of social relationships con-
tribute to obesity. Second, our measure on alcohol consumption was
based on a dichotomous question (i.e., do you ever drink beer, wine,
liquor?). Consequently, the variable was very crude and did not con-
sider the quantity or frequency of alcohol consumption. Using a
more specific measure on alcohol consumption could have a differ-
ent impact on the associations studied but, unfortunately, a variable
with more detailed information on alcohol consumption at both mea-
surement points (1991 and 2000) was not available. Third, the base-
line information is based on data from 1991, and consequently, new
forms of social connectivity could not be considered (e.g., interac-
tion on the Internet, through social media, etc.). In this respect, gen-
eralization of our findings to the present day may be limited due to
changes in the character of social interactions during the last 10-15
years. Fourth, our data analysis was based on only two time points
across a 9-year period. Therefore, we have no additional information
between the two time points, and consequently, possible changes
between the two measurements could not be investigated. Reverse
causality is possible such that increased body weight influences the
social relationship dimensions rather than vice versa. Fifth, BMI
was based on self-reports of weight and height rather than externally
administrated measurements of weight and height, which are more

1546 Obesity | VOLUME 21 | NUMBER 8 | AUGUST 2013 www.obesityjournal.org

Original Article
EPIDEMIOLOGY/GENETICS
reliable. It is possible that individuals underestimated their weight
and overestimated their height. Our use of an algorithm, however,
may have corrected this information bias and minimized this prob-
lem. Finally, we had no information concerning body image and,
consequently, could not test whether the ‘‘body image hypothesis’’
explained some of the patterns in our findings.
In sum, we used longitudinal data from a panel study of the Swedish
adult population to ascertain the associations between social rela-
tionships and obesity among women and men. Our results showed
that various dimensions of social relationships influenced obesity
status during a 9-year period and that these associations were mod-
erated by the sex of the respondents. Moreover, based on our find-
ings, we also discussed some possible mechanisms that may play a
role in the links between social relationships and obesity, although
we were unable to empirically examine the contribution of these
possible mechanisms. In future studies, investigators should follow
individuals regularly with repeated measures of both BMI and social
relationships dimensions (e.g., structural and functional dimensions)
to ascertain the independent effects of these social aspects on obe-
sity. In addition, future studies should also more thoroughly study
the mechanisms linking social relationships and the development of
obesity and whether the operation of these mechanisms differs
between men and women.O
Acknowledgments
The authors thank the government agencies from Brazil and Swe-
den. This study was supported by CAPES—a Brazilian federal gov-
ernment agency research—, FAPERJ—a government agency
research from the State of Rio de Janeiro—and The Swedish Foun-
dation for International Cooperation in Research and Higher Educa-
tion (STINT).
C 2013 The Obesity Society
V 27. Warton DI. Regularized sandwich estimators for analysis of high-dimensional data
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