Obesity and Social Networks – Health Matters
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Obesity and Social Networks – Health Matters

November 10, 2019


Hi, everybody. I’m Dr. David Granet and
welcome to Health Matters. It’s estimated that
up to 66% of the American population is
currently overweight or obese. If you’re not talking
about it right now, you probably were
just a few minutes ago. Recently, there’s been a
new study that talks about the influences
of the environment, your friends
and your family. I’m going to talk about
which is more important on how you look and how
much weight you have. To help us get through this,
we have the author of that study,
Dr. James Fowler, who’s an associate professor
of political science, and we’ll point out that his
doctorate is a PhD, what we call a real doctor. We also have
Dr. Mike Gottschalk who is a professor
of pediatrics and Chief or “El Jefe” of pediatric endocrinology
here at the University of California
San Diego as well. We have you both
here because this crosses disciplines
into effecting everyone. Well, we’ve been
talking about it before we started the show. Everywhere you turn,
there is something about the study
that you guys recently did and it’s just amazing
looking at the social network and how that
can affect weight. Can you give us
a quick summary? And then we’ll delve
into some of the details. Sure. So we got some data from the Framingham
Heart Study which is this really
long-running study. It started actually
in the late 1940s and we’ve learned
a lot of what we know, for example, about
the relationship between heart disease
and smoking from this study. So this study is going
on today even still. And starting in the 1970s,
the study started keeping records on peoples’
friends and family. So we actually got
a grant to map the social network
of the people in the study so that we could see
who was friends with whom and what family members
people had in the study. And because it was
such a small group there in Framingham, a lot of these people
connected up to one another so that we could
see the influence of one person’s weight gain on another person’s
weight gain. Well, you say small,
but it’s like 12,000 people. Yeah, 12,000 people. What I mean by small
is it wasn’t a study of people all
around the country. It was a single
community so that, when people mentioned
who their friends were, they were also likely
to be members of the study. And you had information
about how much they weighed? Absolutely. Again, this is
a gold standard study and they actually
had doctors weigh them every two to four years. So we looked across
the seven different exams, 32 years, to see what
happened as one person gained weight to their
friends and to their family. What we found was
really stunning. We thought we would
find something, but we didn’t realize
the effects would be so large. We found that,
if your friend becomes obese, it increases your own risk
of obesity by 57%. But what if your
family member is obese? Also, we found, if your
siblings become obese, it increases your risk
by 40% and, if your spouse becomes obese,
it increases your risk by 37%. See, I’m still shocked
by that because it would seem to me that your spouse
who you’re with every day would have more of an impact
on you than a friend, but it was not that way. It’s funny you should
mention that because, when we first started
doing the modeling, we looked at that result
and we thought nobody is going to believe this. You know, my wife, she
has less influence on me? I mean, heck,
my wife makes the meals. That’s right, that’s right. Sometimes the husbands
make the meals, but spouses, they spend
a lot of time together. So we looked more carefully
at the friendship data and the sibling data
and what we found in that data is
that same-sex relations were much more important
than opposite sex relations. So men apparently
looked to men and women looked
to other women more than to members
of the opposite sex. So while spouses spend
a lot of time together and on average are
really good friends with one another, they’re also
members of the opposite sex. So those two factors will
work against one another. And my wife told me
that many years ago, that she doesn’t dress
for me or the other men. She’s dressing
for the women because they all look
at each other. So it made sense
to me because I’ve been educated on
that aspect already. Now when you heard
the results of this as a clinician
dealing with weight issues, especially in children,
were you surprised or did you expect
the family relationships to be more important? Well, I think, with children,
we’re in a little bit more of a unique situation
because the parents and the family have
a tremendous influence on the child. For example, the parents
buy the food, the child has some
access to it. So some of
the decision-making that goes on in terms
of lifestyles are really controlled
still by parents. But we were surprised
because I think this is a novel paradigm
that really hasn’t been explored before. And as we’re trying
to go forward and trying to prevent obesity, as well as potentially
come up with regiments to treat obesity,
you really have to understand what are all
the variables in terms of barriers and
what’s driving this. If we don’t
understand that, then no matter what
we come up with a scheme, we’re not going to be
very successful with. I mean, some of the
impacts on this, I was thinking
about as a physician on trying to impact
someone to get them to start an exercise program
or something. One of the things
that was, I think, the most powerful effect
in this study that you wrote was that,
if two people said each other were friends,
the number skyrocketed on the effect. Absolutely. So these forms that we collected
the information from asked people
to name a close friend who would know where you lived
two to four years from now. So we had three different
kinds of relationships. So I could name
you as a friend so we could see your effect
on me or my effect on you, or we could both name
each other as a friend. It makes sense that, if we
name each other as a friend, that that’s probably evidence
of a stronger relationship and we found there a much,
much stronger influence between mutual friends
than between friends where only one person
named the other person. The other really
interesting thing, in these association
studies, we really have
evidence of causality, but what we found was, if I name you as a friend
and you become obese, it increases
my risk of obesity, but not the other way around. So this is just an effect
of people that we esteem, people that
we name as friends. You may be sort
of blissfully unaware of my existence if I name
you as a friend, right? Then I’m not going
to have an impact on you. So the fact that
the influence seemed to flow in one direction is,
we think, really strong
evidence of causality. Which is amazing. Again, going back
to the actual now putting that into effect,
I’m thinking about trying to change someone’s behavior and you’re talking
to them in the office, but their friend’s obese and the friend’s not
sitting there with you and that friend has
a very powerful effect. It almost changes
the paradigm. It does, and I think
we were talking before. One of the questions comes
is how does influence occur? Is it that the person
is looking for acceptance of the change
in their weight, and they’re going
to be satisfied with the fact that
they’re gaining weight and not want to make a change? If their friends,
though, perceive that that’s not what
should be happening, then trying to get them
to influence the change is going to be
really important. So it becomes difficult,
though, because you can’t get friends over distances
to maybe go to the gym unless they have a webcam
and they can show each other exercising at the same time. But I think there
are other strategies that you can involve within
sort of local friends and close friends and sometimes it’s
already been done because you look at–
there’s a TV show in which they try to get
everybody to lose weight at the same time and they
make it a competition. There are organizations
where, you know, at work, they said, okay, as a group,
we’re going to lose 80 pounds, so I think there’s
a very social networking going on and that’s
how this sort of pull and tug that you can
bring people along together and maybe more effective
than trying to just look at individuals in isolation. Absolutely. Well, that’s an interesting
way to discuss even spending money from
a public health standpoint is influencing the social
network at a workplace rather than the individual
in front of you. Absolutely, and another
interesting thing about the study,
because we have these maps of the social network,
we not only knew what was happening
between friends, but between friends’ friends. So you may have a friend
and I don’t know that person and, if you
and I are close friends, that person’s weight
also affects my weight. In fact, it extends to your
friends’ friends’ friends, three degrees of separation
into the network. So people that
you’ve never met, you have an influence
on them and they have
an influence on you. Somehow whenever I drop my son
off at elementary school, there are all these people who
are in their workout clothes. You start to see–I looked
at the world differently after reading your report and
looking at these influences that are all around us
of who we respect and who we are friends
with and what they look like in a way that I never
would have before, especially in
the application to medicine. I still find it amazing
what you found. Though it’s interesting
because we found the what, but we still don’t
know the why, right? So there’s is this association
that does appear to flow in one direction,
but why is the case? Is it because of acceptance of
larger body sizes over time? Is it because of shared
norms about eating, shared norms about exercise? Those are things that
we really need to explore in order to be able
to give better advice on what these
interventions should be when you get your friends
and family involved in your own health behaviors. And we clearly
want to start this early. I mean, we want people
to have good behavior early. You’re involved
with the PACE program. Correct. Could you tell us
a little bit about that? So this is a study trying
to make changes in lifestyle both in respect
to eating and exercising. We’re working with children
who are at risk for developing
Type 2 diabetes. So they’re overweight,
they may have a strong history
of Type 2 diabetes in their family, usually
there are certain ethnic minorities
such as African Americans, Hispanics in this community,
Asian Americans. What we want to do
to see if through behavior modification,
but hook the adolescent to something that
they use commonly, and that’s the Internet
or cell phones. So the idea is that they go to
a website on a weekly basis, they log in and they
have been asked to select goals that
they’re going to make in terms of diet
and exercise. For diet, we use what’s called
the Stoplight Diet so foods are broken down
into reds, yellows and greens, not the color of the food, but these are
not healthy foods, these are better selections… The different curries. So even though peas are green, we won’t get a lot of kids
going to that direction. And what we’d like to see is,
when they enter the study, we take inventory of
what their typical diet is and their selections and
their preferences and then, at the end of the year,
to see if we can shift from more out of the reds
more toward the yellows and greens and,
conversely, trying to get them to increase
their daily physical activity. So they wear pedometers
which keeps track of how many steps
they’re taking, and the goal is over time
at the increased amount of physical activity. So the behavioral part
comes in is that they go on, they log onto a website,
they can see. They select their goals. It’s not that
we’re prescribing what they have to do. They have choices to make
based on what their preferences are,
which I think is really the only way that
you’re going to affect change in the individual. And then they get feedback
because they see the changes they made over each week,
they get rewards. We use a lot
of music downloads because we’re dealing
with adolescents. This is social networking. Do they get to talk
to other kids who are living through this
at the same time? One of the arms is, not only do they have
this internet access, but they come back for
sessions with other kids within that same group,
so they interact. And we bring parents, too,
so the parents have a piece of this as well. This, again, goes back
to influences and, certainly from my
own clinical experience, I think the children that are
most successful losing weight is when we get the parents to
lose weight at the same time. Because if the parents
see changes and they’re feeling better
about themselves, then they’re going
to just pull that kid out the door with them and
go for a walk with the dog. That’s how that’s how
they effect change. So when the groups
come back together, it’s been very
interesting to see because they share
their experiences and see what’s
successful for them, what’s worked for them,
what hasn’t, what are their challenges,
what obstacles do they still have and how
do they perceive themselves. You started this program
before the study that Dr. Fowler had done
and came out, but you were hitting on
the same sort of principles of the influences. I think the influences
in his study are even different
than what we considered typical influences because I think
certainly with adolescence, peers are very important. You know, this is a time
where they’re moving away from their parents and trying
to develop independence, so their peer network
is really important. It may not always be,
though, that they consider all their peers are
sort of their best friends, but they survive under
this peer pressure. That’s a little bit
different than I think what you’re describing,
but certainly this has to also exist
for the adolescents as well and it’s important
to realize that so we can tap into that and
use that to our advantage. When I was reading
about the PACE program, one of the things that hit me
was that the obese adolescent may become antisocial
or isolated and then their
social network is reduced to their family, which
becomes their influence. Then I started thinking,
well, getting their parents to lose weight
is obviously important, but their parents aren’t
going to lose weight unless they have a friend
whose influence– You know, you start trying
to do those dominoes and making them fall, of
trying to impact all that, you got this kid that
you’re trying to help who’s at risk for diabetes and you want to get
the parents to go, but the parents
are going out for barbecue every night
with their social group that plays cards
together or something. How do you make those
changes and it starts to become a pretty big issue. I just want
to emphasize something about this particular issue. It certainly is the case
that obesity is associated with social isolation and
a lot of people, I think, interpreted the results
of our study to be that, if you have a friend
who becomes obese, that you should stop
being friends with them. That’s not at all
the message of our study. We studied existing
friendships, right? So there’s nothing
that you can infer from our study about,
you know, getting rid of your friend
or getting a new friend who might have healthy
eating behaviors. We looked at the
existing network, but there’s this huge
literature on social support that shows that,
when you have more friends, you’re healthier. You get more support, you
feel better about yourself. There’s sort of a number
of causal mechanisms that cause us to
become healthier when we have more friends. There was so much
kind of controversy on this point
with the study that I actually went
back to our data and looked to see
what happened to people who got rid of friends
once they became obese. So you actually had the data
so that, if their friend changed weight
and gained weight and then you looked back
the next visit and they’re no
longer friends… – That’s right.
– What happens to them? It increases the risk
of obesity, yes. So getting rid of the friend
actually increased their risk. That’s right. So on balance, you may
gain something from having a set of
friends who are engaged in healthy behaviors,
but what you lose from losing the friend
is actually much worse. So the last message
you should take from this study is
to get rid of any friend. So the best message
might be you and your friend together
lose weight. Absolutely, and I think
that a lot of people already understood
this, right? I mean, some people
reacted to the study, oh, that’s really neat,
and others reacted, well, duh. I knew that the best way
for me to be able to change my own behaviors
is to get my friends and family involved. I mean, you have
WeightWatchers. In other domains, you
have Alcoholics Anonymous. These are groups that
have already understood very well that social networks
are really the core for a successful change
in your lifestyle. But no one had looked at it
quite like you had before. We just didn’t
have the data before. Now we have the data and we can
really confirm our intuitions. So there are a lot of people
who spend time watching TV. Often adolescents
fall into that category. There are role models
that fall into TV. There are from MTV videos to
people we see on television. How do we fit that impact
into what the social norm is or behavior for people? It’s not your friend? I think that people sort of
think about them that way, but they’re not truly friends. Where does that fit, a role of
television playing in weight? Good question. One of the things that our
study really indicates is that you have to be
very good friends with somebody in order
for there to be an effect. So, for example,
we looked at the effect of immediate neighbors
and there was no effect. So that can be someone that
you actually see frequently, but you’re not necessarily
very close to them. And if they become obese,
it has absolutely no impact on you. Also, the sort
of the stronger… So if my neighbors are
listening, they can… That’s right, so they can go
ahead and eat the extra steak. They can breath easy. But the idea is that
this has to be someone that you’re very close to, close friends,
close family members. So the idea
that television watching or sort of these
relationships on the Internet are going to influence this. You know, seeing models on TV
or the thousands of people you’re connected to
in Facebook, those people are
not going to matter. The people that are
going to matter are going to be the people
that you’re deeply and closely socially
connected to. Can you compare that effect
to other effects? In other words, eating habits,
activity of lifestyle. Is it all tied in or is this
just one piece of the puzzle? We certainly expected them
to be tied. Actually, you might know
a little bit more about this than we do because
we’ve really just tried to state what the association
is between different individual’s weight. I do know that the next thing
we’re going to be studying is what foods people
are eating in this network. So we just got a grant
to do this and they took a food
frequency questionnaire where they asked
detailed questions about what people ate. So just as a tongue
in cheek example, we drew the banana-eating
network. How many bananas
do you eat a week? But this is going
to obviously feed into– you know, we can categorize
these foods as green, yellow and red. I can imagine green circles,
yellow circles and red circles all sort of connected
to each other and you can see the extent
to which good eating behavior or bad eating behavior flows and how it’s related
to obesity. And you probably predict
that those food color networks would match up with
the friendship networks and obesity.
I mean, they overlap. That’s certainly
what we expect, but that work
has yet to be done. And it goes together with
what you’re trying to do with PACE and the other
work that you do trying to change
that behavior and where to get
the levering to do it. I think what’s
interesting about this study, again, is that these
sort of transitioned over distances and,
like you said, you can be three or
persons removed. So it’s a little
difficult to imagine that it’s going to be
just how you eat because how would
that fourth person really know how the
first person is eating? It’s sort of like
the old telephone game when we were younger kids
and your whispered message was totally different
at the end. Right. So as you start moving
down the links, I think you start
to lose some of the effect – and some influence.
– Absolutely. But I think it still
goes back more to, as you talked about,
friendships and how people perceive each other
and acceptance of their perception. My wife’s a runner,
so she’s friends with other people
who run who are friends with other people who run and that’s the way
I looked at it, that they have
common interests that lead them
in certain directions. We’ll see how it holds up. That’s probably true. I should emphasize the fact
that the effect gets smaller as you get further away. So by the time
you’re four degrees removed, there’s not
an effect, right? So the strongest ones
are the ones we’re directly connected to. So it is like
the game of telephone. Eventually, you know,
it’s noise. I had a couple of myths
that I made sure I wanted to ask you
and you answered two of them already. The third one I had was,
is obesity contagious? Is it infectious? Or is the idea of obesity
what goes on? Is there a virus that they’re
spreading amongst friends? I think the ideas
are infectious. So we think
this is about norms. One of the aspects of the study
that was really interesting is that, when
we looked at friends who were thousands
of miles away versus friends
who lived very close, the effect was pretty
much the same size. So this indicates
that it’s not because we’re going
running with a friend or we’re eating
with a friend. These are really
about us exchanging ideas about what healthy eating
and healthy exercise behavior is and what
a healthy lifestyle is. I mean, these are people that
you could see once a year and they still have
a tremendous effect on who you are. It’s very impressive when
we talk about it this way. He’s getting grants
to do all this. He’s getting a lot
of money to do all this. How important is it that we
talk about obesity and weight? Well, it’s tremendous
because the change in the prevalence of obesity
has just been staggering in the United States. The prevalence has
doubled to tripled in certain populations. Certainly, adults now, 60%,
over two-thirds, people are considered
to be overweight and a third are obese
and the children’s prevalence are just trailing behind at just about
a decade beyond that. As you’re well aware,
there are so many medical complications
to obesity starting from developing
insulin resistance and causing potentially the
increase of Type 2 diabetes. As an pediatric
endocrinologist, when I started 17 years ago, I never saw a child
with Type 2 which we typically
associate with adults. Now 25% of the children
we see with new onset have Type 2 diabetes. And that’s really
related to weight? It’s really related
to weight because this has changed too rapidly
to be a genetic influence. It’s clearly an environmental
influence in change. It’s estimated right now,
for example, that every child
that’s born today, if the prevalence
of obesity continues at its current
escalating rate, that a third
of those individuals will develop diabetes by
the time they’re adults. Wow. A third? A third, so there are
quite staggering figures. Not only do we see
within the terms of the realm of diabetes,
but children are developing a disease
or fatty infiltration of the liver and
that can actually go on and develop cirrhosis, so there’s a much
higher prevalence of this disorder now. We see a lot of orthopedic
problems because of obesity. Sleep apnea is another
significant problem that we’re seeing, and this is being parlayed
into the adult world as well. Now you’re doing some
other work on smoking and drinking and happiness? Yeah, yeah, so smoking,
we just submitted a paper and one of
the interesting things there is you can look at
the cluster sizes of smokers. So how many smokers
are sort of connected to each other? The incidence of smoking
has dramatically decreased over the last 30 years,
so in some sense, it’s sort of the mirror image
of the obesity epidemic. But the size of these clusters
has remained the same, the average size. What that means,
if those two things are happening at once,
is that whole groups of people are
quitting together. So this is sort of the main
sort of interesting point. It’s not people sort
of at the edge of a social network
that are quitting. It’s whole groups of people. One person quits,
then everybody in the group quits. But that’s proof of concept
in essence of the PACE program and
these other programs being able to get groups
together to make an impact, reversing that effect. Right, assuming that
the same mechanisms work for smoking
as they do for obesity. We hope that’s the case. You know, as a doctor,
again, is there anything good about smoking? Not that I can think of. Nothing good about smoking, and is there anything good
about being obese? No. I mean, these are
lifestyle changes, these are things that people
can do for themselves. If somebody came
to your office and there was things
you could do to help them to lose weight
and you didn’t, they’d be furious with you. Yet there are things
that people can get involved themselves
to make a difference, and smoking is like that,
obesity is like that. And if these networks continue
to hold up that way, you may have helped
us identify– and you’ve already
been working in that world– but even sharpen
our tools to influence those networks to get
positive behaviors. I certainly hope so. I mean, that’s a big
motivation of mine. I have members of my family
who are afflicted with obesity and
I would love it if something that I did–
so often it’s up in the sky– but if something I did
actually had a positive impact on their lives, I would
just be thrilled. So you have to take a moment
and tell us about the happiness study. Okay, yes. We also are
studying happiness. They gave this
depression questionnaire to individuals in
the Framingham Heart Study and part of that
questionnaire are several questions
on happiness. And what we’re finding
there is that happiness spreads from person
to person as well. This is really interesting
because we already know that there are
these short-term effects of happiness. If I smile, it increases
the chances that you’ll smile
and vice versa. It is locally contagious. But there have been
these other studies that show that
happiness is fleeting. So, for example,
if you win the lottery, you’ll increase the amount
of happiness that you have for about a year,
but then after that, you’re just as happy
or unhappy as you were before you won
all the money. Well, because you spent
all the money by then. Perhaps, yeah. But it’s interesting because
you sort of think that, you know, if only I could
just have a million dollars, I’ll be set and, as it
turns out, it’s fleeting. The interesting thing
is that we find that these exams that happen
every two to four years indicate that, over
the long term, whenever your friend
becomes happier increases your
own happiness. I mean, that’s amazing. We have about two minutes
left in the show and I wanted to give
you a chance to talk about if you could control
the world in the future, taking some of
these principles, the PACE study that
you’ve been working on, the networking that
we’re talking about, how would we impact schools,
public health? Where do you see
this going one day? Well, I think certainly
schools are a great place for us to have an impact
because they give us, first of all,
an educational opportunity and there have been
some unique programs already developed
for schools. We take the attitude that,
well, we can explain that you’re overweight
and you have to make these changes and
you’re going to do it. But if we try to do it
more from an educational point of view,
to explain why you should make healthy choices
and here are examples, and then let the schools
have the environment where they can make
a healthy choice, it’s kind of silly for us
to talk about making healthy choices and
then they can go buy soda or they could buy
Flaming Hot Cheetos from the vending machines
to do that. If we’re going to effect
the change in the house, this is a great place
to making a change because, if the child comes
home and says, oh, you know, I really like getting apples, I don’t want to eat
the Fritos that you’re giving me
all the time, potato chips, then maybe we can
affect a change within the house as well. So understanding
and I think certainly the study you were
just talking about with the smokers quitting in
a cluster is very encouraging because it does give
weight to the evidence that we need to maybe think
about these networks and attack a network
as opposed to just looking at an
individual to do that. We see that all the time,
again, in children. We can’t just say
to a family where everybody in the family is obese
and we’re just talking about the eight-year-old child
and say you have to make a change
and the other family members are allowed to continue
to do whatever they were doing before,
you’ll have no success at all. Well, that’s neat. This is exciting and
I’m so glad both of you could come join us
to talk about this because it’s of
interest anyway, but it has impact
on peoples’ lives and health. Whether you know it or not,
you’ve already impacted people and changed their health
as a political scientist. That’s what doctors do, okay? That’s what M.D. doctors do,
not the PhD doctors do. I mean, congratulations
on an incredible study and I know that you’re
going to be continuing to work on this and I think
that’s just spectacular. And thank you for coming
to talk to us about how important all this
is and how meaningful it is. – Thank you.
– Thank you. I appreciate you both
taking the time with us. You just heard
an incredible discussion about the impact
that your social network which includes your friends,
but for kids, their family network,
what that can have on your life and health. And the trick isn’t
to get rid of your friends that have it, like,
if they’re obese. Because that doesn’t work,
we know that. But remember that
you do have influence and that you can change
and that actually can help the people
around you as well. So let’s take advantage of
these networks and flip them. Knowledge is power. The more you know,
the more you can affect your own health and,
as it turns out, the health of your friends
and your family. I’m Dr. David Granet. This has been Health Matters. We’ll see you again next time.

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