RISK FACTORS

The contribution of lifestyle factors to socioeconomic dierences in obesity

in men and women a population-based study in Sweden
Anu Molarius
Centre for Public Health Research, Karlstad University, Karlstad, Sweden
Accepted in revised form 4 October 2002
Abstract. Background: The objective was to investi-
gate whether and to what extent the association be-
tween socioeconomic status and obesity can be
explained by lifestyle factors. Methods: The rela-
tionship between socioeconomic status (SES) and
obesity, and the role of lifestyle factors such as
smoking, physical activity, heavy alcohol use, avoi-
dance of dietary fat and propensity to eat ber-rich
food, was studied in a cross-sectional population-
based study consisting of 6394 men and women aged
2574 years in Va rmland County in Sweden. Edu-
cational level was used for measuring SES. The
contribution of the measured lifestyle factors was
assessed using logistic regression models. Results:
12% of men and 14% of women were obese. Subjects
with high education were leaner than subjects with
low education, except among elderly women (65
74 years). Although many lifestyle factors were re-
lated to obesity and SES in this study, only a part
(1829%) of the association between educational
level and obesity could be explained by the measured
lifestyle factors. Physical inactivity and heavy alcohol
use were the main factors contributing to this asso-
ciation, whereas smoking and the measured dietary
attitudes towards fat and ber had little additional
eect. Conclusions: The ndings of this study are
consistent with the view that socioeconomic dier-
ences in obesity and its consequences can only partly
be reduced by changes in lifestyle. Longitudinal
studies, a more detailed investigation of the role of
dietary factors and more studies including elderly
subjects are, however, recommended to further elu-
cidate the association between SES and obesity.
Key words: Lifestyle, Obesity, Population studies, Socioeconomic status
Background
An inverse association between socioeconomic status
(SES) and relative body weight has been observed
among women in auent societies [1, 2]. The asso-
ciation is less consistent among men, although in
most western countries an inverse association has
also been found in men. Likewise, in Sweden persons
with high SES are leaner than persons with low SES
[35] and this association has been rather stable
during the last decade [5].
Socioeconomic inequalities in self-perceived health,
morbidity and mortality exist in many countries [6].
Because obesity is related to the incidence of several
chronic diseases and mortality [710], socioeconomic
dierences in the prevalence of obesity may act as one
factor through which these inequalities emerge [11].
Therefore it is important to investigate possible ex-
planations for socioeconomic dierences in obesity.
Lifestyle factors, such as physical activity, dietary
habits, smoking and alcohol intake are related to
relative weight [1215] and also dier between so-
cioeconomic groups in such a way that the most
privileged often have healthier lifestyle [6, 1618].
Because these behavioural factors are potentially
modiable, it is of interest to know whether and to
what extent the association between SES and obesity
can be explained by these factors. Some studies have
suggested that dierences in health behaviour only
partly explain the association between SES and rel-
ative weight [11, 1921]. These studies have, however,
not been population-based and they have studied
subjects only within a limited age range e.g. they have
not included elderly subjects. There are also meth-
odological shortcomings in measuring lifestyle factors
in these studies. Therefore the evidence remains in-
conclusive.
In the present study the relationship between SES
and obesity, and the role of lifestyle factors in this
relationship, was investigated in a cross-sectional
population-based study consisting of 6394 men and
women aged 2574 years in the Va rmland County in
Sweden. Educational level was used for measuring
SES.
Methods
The data were derived from a random sample of the
adult population aged 1879 years in Va rmland
European Journal of Epidemiology 18: 227234, 2003.
2003 Kluwer Academic Publishers. Printed in the Netherlands.
County in western Sweden. The data were gathered
between 21 March and 19 May 2000 using a postal
survey questionnaire. The overall response rate was
70%. A total of 8288 subjects answered the ques-
tionnaire. Because most of those aged 1824 years
had not completed their education and the informa-
tion on education was missing for most of those aged
75 years or over, these age groups were excluded
from the study. 6394 men and women aged 25
74 years with data on body mass index (BMI) and
educational level were included in the study.
Relative weight was measured using BMI. BMI
was calculated from self-reported weight and height
as weight divided with height squared (kg/m
2
). The
participants were categorised in concordance with the
WHO guidelines [22] as obese when BMI was equal
to or over 30 kg/m
2
.
Educational level was obtained through record
linkage from a national education register. The re-
cord linkage was carried out by means of personal
identication codes. Educational level refers to the
end of year 1999 and it was categorised into three
classes: low (elementary school), medium (upper
secondary school), and high (at least 3 years of uni-
versity or corresponding education).
Data on lifestyle factors were obtained using the
questionnaire. Physical activity was measured with a
question: How much do you exercise physically in
your leisure time? with the options little exercise
(walking, bicycling or other light exercise less than
2 hours a week), moderate exercise (walking, bicy-
cling or other light exercise more than 2 hours a
week), moderate regular exercise (exercising 12
times a week at least for half an hour at a time in
jogging, playing tennis, bicycling, exercising at a gym
or other moderate exercise that makes one to sweat)
and vigorous exercise and training (exercising or
competing at least three times a week at least for half
an hour at a time in team sports, jogging, playing
tennis, swimming or other vigorous exercise). Because
the survey was carried out between late March and
May, the possibilities for example for walking are not
aected by winter circumstances in this area of
Sweden.
Smoking was asked with a question: Do you
smoke? with the answer options No, I have never
smoked regularly, No, I have stopped smoking,
Yes, occasionally, and Yes, daily. Alcohol use was
obtained with a question asking how often it hap-
pened that the subject drank at the same occasion
alcohol corresponding to at least half a bottle of
strong liquor (with giving the corresponding amount
in wine and beer). The options ranged from At least
ve times a week to Never, and were for the anal-
ysis grouped into three categories Once a month or
more often, More seldom and Never.
There was no information about actual intake of
fat and ber, but dietary attitudes towards fat and
ber were asked with a question: Do you try to avoid
fat food? and Do you try to eat ber-rich food (such
as wholemeal bread, mu sli or root vegetables)?. The
answer options were Not at all, Yes, to some ex-
tent, and Yes, I am very particular about it.
Statistical methods
As background information the prevalence of obesi-
ty, low education and the measured unhealthy life-
style factors are reported by three age categories
(2544, 4564, and 6574 years), and the prevalence
of obesity and unhealthy lifestyle factors by educa-
tional level. The association between educational
level and relative weight was assessed by calculating
the dierence in mean BMI between the educational
levels in the three age categories (with further ad-
justment for age) in a general linear model.
The contribution of lifestyle factors to the associ-
ation between educational level and obesity was
studied using logistic regression models where obesity
was the dependent variable. The contribution of each
lifestyle factor was assessed by adding these factors
one by one into the model containing obesity and
educational level. Smoking was added rst, then
physical activity and heavy alcohol use, and nally
dietary attitudes. Smoking was added rst, because
an inverse association was assumed [14] and dietary
attitudes last, because only an indirect association
was assumed. Only those factors that were associated
with obesity were included in the nal model. Because
age was strongly related to both obesity and educa-
tional level, all models were adjusted for age. Since
the association between age and obesity was non-
linear, age was used as a categorical variable (5-year
age classes). Because there was no association be-
tween educational level and relative weight among
women aged 6574 years, these were excluded from
further analysis. All analyses were performed sepa-
rately for men and women.
To conrm the results between obesity, SES and
lifestyle factors obtained in the logistic regression
analysis, the same analyses were repeated using gen-
eral linear models where BMI was the continuous
dependent variable.
The contribution of lifestyle factors to the associ-
ation between SES and obesity was calculated as the
proportion (percentage) of the dierence in the odds
ratios between the crude model (C) and the model
including the lifestyle factors (nal model, F) in re-
lation to the increased risk in the crude model:
100 OR
C
OR
F

OR
C
1
%
In the corresponding general linear model the con-
tribution of lifestyle factors to the association be-
tween SES and BMI was calculated as the
proportional change in the dierence in mean BMI
between the educational categories before and after
adjustment for the measured lifestyle factors.
228
Results
Table 1 shows the number of participants and the
prevalences of obesity and low education by gender
and age group. Obesity was relatively common in the
study population, 12% of men and 14% of women
were obese. Obesity increased with age, except among
men in the oldest age group. The proportion of
subjects with low education increased strongly with
age. The table also shows the proportion of physi-
cally inactive, daily smokers, heavy alcohol users and
subjects with unhealthy dietary attitudes. About one-
fth of the population was physically inactive and
physical inactivity was most common among young
(2544 years) men. It was the moderate exercise
which increased with age in men, whereas vigorous
exercise decreased with age. Women were more often
smokers than men, except among the elderly (65
74 years). Heavy use of alcohol was very common
among men, especially among young men, almost
half of them consumed alcohol corresponding to half
a bottle strong liquor at least once a month. Dietary
attitudes showed a similar pattern as heavy alcohol
use. Women were more often than men trying to
avoid fat food and to eat ber-rich food. Older sub-
jects had healthier dietary attitudes than younger
subjects.
Obesity was more common among subjects with
low education than among subjects with high edu-
cation (Table 2). Also lifestyle habits diered con-
siderably between the educational levels. Those with
low education were more often physically inactive,
smokers, used more often alcohol and had un-
healthier dietary attitudes than those with high edu-
cation. Those with middle level education were,
however, even more often heavy alcohol users and
had unhealthier dietary attitudes (among men) than
those with low education. Because also age diered
between the educational levels (Table 2) and it was
related to lifestyle factors (Table 1) the subsequent
analyses were adjusted for age.
Figure 1 shows the dierences in mean BMI be-
tween the high and low educational levels in men and
women in the three age categories. Subjects with high
education were leaner than subjects with low educa-
tion in all age groups among men. A similar inverse
association was observed among women aged 25
64 years, this association was particularly strong
among women aged 4564 years. There was, how-
ever, no association between educational level and
relative weight among elderly (6574 years) women.
Subjects with high educational level were also leaner
than subjects with middle level education in all age
groups except in elderly women (now shown).
Table 1. Number of subjects, prevalence of obesity, low education, physical inactivity, daily smoking, heavy alcohol use,
and unhealthy dietary attitudes by age group in men and women (crude percentages)
Men Women
Age group 2544 4564 6574 2544 4564 6574
n 1033 1124 872 1233 1285 847
Obese (%) 10.9 13.2 12.7 10.6 14.2 17.5
Low education (%) 14.8 38.4 59.6 12.7 27.7 57.4
Physically inactive (%) 27.1 22.7 17.3 19.0 21.2 18.3
Daily smokers (%) 13.2 17.2 13.3 21.0 22.0 10.7
Heavy alcohol use at least once a month (%) 43.9 28.3 19.5 13.0 9.0 3.2
Does not try to avoid fat food (%) 54.1 37.8 32.0 27.3 12.9 13.2
Does not try to eat ber-rich food (%) 47.2 28.6 17.7 22.7 11.6 8.9
Table 2. Number of subjects, mean age, prevalence of obesity, physical inactivity, daily smoking, heavy alcohol use, and
unhealthy dietary attitudes by educational level in men and women (crude percentages)
Men Women
Educational level Low Medium High Low Medium High
n 1155 1716 208 991 2061 313
Mean age (SD) 59.5 (12.4) 47.1 (14.3) 52.7 (13.7) 59.4 (13.2) 47.0 (13.9) 48.8 (13.3)
Obese (%) 14.8 11.5 5.3 17.2 13.0 7.7
Physically inactive (%) 21.5 24.8 12.7 23.9 18.2 16.6
Daily smokers (%) 17.6 13.6 8.7 20.3 19.8 7.7
Heavy alcohol use at least once a month (%) 28.1 35.0 15.5 7.7 10.4 3.9
Does not try to avoid fat food (%) 38.2 44.9 33.8 18.5 18.8 14.3
Does not try to eat ber-rich food (%) 28.8 35.4 18.3 16.1 15.3 9.7
229
Table 3 shows the results from the logistic regres-
sion analysis among men aged 2574 years. Physical
inactivity and alcohol use were positively associated
with obesity. The association between obesity and
smoking was not statistically signicant in men
(p 0:41). Dietary attitudes were not associated with
obesity in men when adjusted for the other lifestyle
factors (p 0:28 for avoidance of dietary fat and
p 0:48 for propensity to eat ber-rich food). Phys-
ical inactivity had the strongest association with
obesity. Adjustment for physical exercise and heavy
alcohol use attenuated the risk of obesity between
high and low educational levels by 25% and between
high and medium educational levels by 29%.
Results for women aged 2564 years were to some
extent similar to those for men (Table 4). Adjustment
for lifestyle factors attenuated the risk of obesity
between high and low educational levels by 18%, and
by 21% between high and medium educational levels
in women. Physical inactivity was even more strongly
associated with obesity in women than in men.
Smoking was not related to obesity in women
(p 0:19). Avoidance of dietary fat was related to
obesity in women but in an unexpected way. Those
who did not try to avoid fat food were less often
obese than those who tried to avoid fat food. This
suggests that avoidance of fat food can be interpreted
as a consequence of rather than a risk factor for
obesity in women, i.e. that obese women try to avoid
fat food more often than normal weight women.
Propensity to eat ber-rich food was not associated
with obesity in women (p 0:55).
The results using BMI as a continous dependent
variable (general linear model, not shown) were in
concordance with the results obtained from the lo-
gistic regression analysis. The proportions explained
by the measured lifestyle factors were slightly lower
than for obesity. Twenty-two percent of the dierence
in mean BMI between high and low educational
levels and 24% between high and medium educa-
Figure 1. Dierence in mean BMI (kg/m
2
) in subjects with low educational level compared with subjects with high edu-
cational level in three age categories in men and women (adjusted for age).
Table 3. Odds ratios (95% condence interval in parenthesis) for risk of obesity by educational level adjusted for lifestyle
factors associated with obesity (all models adjusted for age) among men aged 2574 years (n = 2814)
Crude Adj. for physical activity
Adj. for physical activity
and alcohol use
Education, high 1 (ref.) 1 (ref.) 1 (ref.)
Medium 2.4 (1.3, 4.5) 2.2 (1.1, 4.1) 2.0 (1.1, 3.8)
Low 3.0 (1.6, 5.7) 2.7 (1.4, 5.1) 2.5 (1.3, 4.8)
Physical activity, vigorous exercise 1 (ref.)
Moderate regular 1.0 (0.6, 1.7)
Moderate 1.3 (0.8, 1.9)
Inactive 2.4 (1.6, 3.8)
Heavy alcohol use, never 1 (ref.)
More seldom than monthly 1.2 (0.9, 1.6)
Monthly 1.5 (1.1, 2.1)
230
tional levels was explained by the measured lifestyle
factors in men. In women the corresponding pro-
portions were 12 and 20%.
Discussion
As in most other western populations, subjects with
high educational level were leaner than subjects with
low educational level in the present study population
of men and women aged 2564 years. Among the
elderly aged 6574 years, however, there was an in-
verse association between educational level and rel-
ative weight among men only. Although many
lifestyle factors were related to obesity and SES in
this study, only a part (1829%) of the association
between educational level and obesity could be ex-
plained by the measured lifestyle factors. The con-
tribution of the measured lifestyle factors was
somewhat bigger in men than in women. Physical
inactivity and heavy alcohol use were the main fac-
tors contributing to the association between educa-
tional level and obesity, whereas smoking and dietary
attitudes towards fat and ber had little additional
eect on this association.
The total caloric intake, the actual intake of fat and
other dietary components were not measured in the
present study. There were only two questions about
diet and these are not sucient to measure unhealthy
dietary habits. Measuring dietary intake has been
found to be dicult since there is a considerable
underreporting of caloric intake among the obese
subjects and the underreporting seems to be food-
specic [23, 24]. This might also be the reason why
evidence on the association between dietary habits
and SES is mixed [2527]. In addition, dietary ber,
but not fat, has been found to some extent explain
dierences in prevalences of obesity between popu-
lations [28]. In the present study, there were socio-
economic dierences in avoiding fat food and trying
to eat ber-rich food. These factors were however not
related to obesity when adjusted for the other mea-
sured lifestyle factors, except trying to avoid fat food
which was inversely related to obesity in women. The
latter implies that obese women are more often trying
to avoid fat food than non-obese women. Whether
their actual fat intake is lower that of non-obese
women cannot be assessed from the present data.
Wamala et al. [21] found that unhealthy dietary
habits were the second strongest factor after repro-
ductive history accounting for socioeconomic dier-
ences in obesity among middle-aged women. A more
careful study about the role of the dietary habits in
the general population is therefore warranted, espe-
cially an investigation how dietary habits contribute
to deliberate weight control.
Because alcohol has high caloric density, alcohol
intake is usually associated with obesity. In some
studies alcohol intake has not been associated with
relative weight which might be due to diculties in
measuring alcohol intake accurately [2931]. In ad-
dition, the association has been found to dier be-
tween men and women, with a positive association
often found in men but a negative association in
women [30]. This may be due to the fact that the same
cut-o points for alcohol intake have usually been
used both for men and women whereas the actual
intake is much lower in women than in men. In this
study the actual alcohol intake was not measured but
the subjects were instead asked about the frequency
of heavy alcohol use. Heavy alcohol use was related
to both obesity and low SES and explained part of
Table 4. Odds ratios (95% condence interval in parenthesis) for risk of obesity by educational level adjusted for lifestyle
factors associated with obesity (all models adjusted for age) among women aged 2564 years (n = 2406)
Crude
Adj. for physical
activity
Adj. for physical
activity and
alcohol use
Adj. for physical activ-
ity, alcohol use and
avoidance of dietary fat
Education, high 1 (ref.) 1 (ref.) 1 (ref.) 1 (ref.)
Medium 2.4 (1.4, 4.1) 2.2 (1.3, 4.0) 2.2 (1.3, 3.8) 2.1 (1.2, 3.7)
Low 2.7 (1.5. 4.8) 2.4 (1.3, 4.4) 2.3 (1.3, 4.2) 2.4 (1.3, 4.2)
Physical activity, vigorous
exercise
1 (ref.)
Moderate regular 2.8 (1.3, 6.1)
Moderate 4.8 (2.3, 9.9)
Inactive 9.6 (4.6, 20.3)
Heavy alcohol use, never 1 (ref.)
More seldom than monthly 1.2 (0.9, 1.6)
Monthly 2.0 (1.1, 2.3)
Tries to avoid fat food, very
eagerly
1 (ref.)
To some degree 0.6 (0.5, 0.9)
Not at all 0.4 (0.2, 0.6)
231
the dierences in obesity by SES. This eect was
more marked in men than in women.
Smoking was not associated with obesity in the
present study. Even though an inverse association
between smoking and obesity has been reported for
most countries, there are studies that have shown a
lack of association between smoking and obesity in
other populations with low prevalences of smoking
[14]. This might be due to that in countries with very
low smoking prevalence smokers are a selected group
of people with also other unhealthy lifestyle habits.
The nding that there was an inverse association
between SES and obesity among elderly men but not
among elderly women has no immediate explanation.
Most studies on socioeconomic dierences in obesity
have investigated middle-aged or working-age popu-
lations [2, 5, 11, 1921, 32] and those which have
included elderly have not studied them separately [3,
4, 33]. The increase in obesity after the age of 65 years
in women (but not in men), changes in the educa-
tional system over the past decades, the small number
of elderly women with high educational level, and
possible overrepresentation of diseases which lead to
weigth reduction among low educated subjects are
factors that may have contributed to the lack of as-
sociation between SES and obesity in elderly women.
The association between SES and obesity among el-
derly requires further research.
In the present study data on weight and height
were self-reported. Self-reported data have been
found to underestimate the actual prevalence of
overweight and obesity [34, 35]. This would, however,
more likely lead to an underestimation of the
relationship between SES and obesity than to over-
estimate it, since the distribution of BMI using self-
reported data becomes more limited. Socioeconomic
dierences in self-report bias cannot, however, be
excluded. For example, high SES subjects (who are
more health conscious) may underestimate their
weight and overestimate their physical activity more
often than low SES subjects. In that case there would
be an overestimation of the association between SES
and obesity and the contribution of physical activity
to this association. Similarly, there is a possiblity of
underreporting of heavy alcohol use in the high SES
subjects. This would overestimate the contribution of
alcohol intake on the relationship between SES and
obesity. The data on educational level were obtained
from a national register and the quality of these data
is considered to be good.
The present study was cross-sectional in design and
cannot therefore be used for drawing causal infer-
ences about the association between SES and obesity,
and the role of lifestyle factors in this association.
Even though many lifestyle factors are known to be
determinants of obesity, sometimes the reverse may
also be true. For example, even if physical activity is
known to be a strong determinant of obesity, obese
subjects may nd it dicult to carry out physical
exercise, especially strenuous physical activity [36].
The same applies to the ndings concerning dietary
attitudes in the present study: it is likely that it is the
obese women who are most often trying to avoid fat
food and not those trying to avoid fat food who are
most often obese.
The response rate in our study was relatively high
(70%) for a postal questionnaire. When the respon-
dents were compared with non-respondents, it was
found that the respondents had slightly higher edu-
cational level. Response rate among subjects with
high educational level was 78% and among subjects
with low educational level 65%. The response rate
was also higher among older (77% in age group 65
79 years) than younger subjects (62% in age group
1834 years), and higher among women (75%) than
men (66%). It is, however, unlikely that the associa-
tions between SES, obesity and lifestyle factors ob-
served among the respondents would dier to such an
extent among the non-respondents that this would
considerably aect the results.
The results of this study are in concordance with
results from other studies where lifestyle factors have
been found to only partly explain the socioeconomic
dierences in obesity [19, 20]. It also suggests that the
nding holds in population-based studies and among
elderly men. Similar ndings have been observed for
weight gain. For example, Martikainen and Marmot
[11] found that adjustment for behavioural factors
attenuated the association between SES and weight
gain by about 20%. This is quite near our estimated
eect of the role of the measured lifestyle factors in
socioeconomic dierences in obesity. It cannot,
however, be excluded that inaccuracies in the mea-
surement of lifestyle factors in this and the other
studies may have contributed to the low contribution
of lifestyle factors in explaining socioeconomic dif-
ferences in obesity.
One possible explanation for the fact that lifestyle
factors only partly explain the socioeconomic dier-
ences in obesity prevalence is that higher SES subjects
may to a greater extent deliberately control their
weight. A recent study among British adults [33]
found that especially high SES women had lower
levels of perceived overweight, monitored their
weight more closely and were more likely to be trying
to loose weight than did low SES women. Another
factor that has been found to explain the excess
overweight among low SES women is reproductive
history (higher parity and earlier age at menarche) [4,
21]. These factors were, however, not measured in the
present study. Also unfavourable psychosocial fac-
tors have been found to be associated with obesity
[32] and factors such as poor quality of life, low self-
esteem and job strain have been mentioned as factors
partly explaining the low SESobesity relationship
[21]. However, although these factors are related to
SES, they can also be interpreted as consequences of
rather than risk factors for obesity and therefore their
232
association with obesity should be investigated in
longitudinal studies.
The contribution of lifestyle factors to the socio-
economic dierences in obesity is important from a
public health point of view. If lifestyle factors would
explain a large part of the association between SES
and obesity, changes in lifestyle would be important
for reducing socioeconomic dierences in obesity.
Furthermore, changes in lifestyle factors would even
be important for reducing the socioeconomic dier-
ences in the consequences of obesity. Since the con-
tribution of lifestyle factors such as physical inactivity
and heavy alcohol use on the basis of this and other
studies seems to be limited, other factors should be at
least as important as lifestyle factors when trying to
reduce the socioeconomic dierences in obesity. Ex-
amples of such possible other factors are reproductive
history in women, deliberate weight control practises
and cultural factors such as what is considered as
desirable weight.
In conclusion, although many lifestyle factors were
related to obesity and SES in men and women, only a
part of the association between educational level and
obesity could be explained by the measured lifestyle
factors. Longitudinal studies, a more detailed inves-
tigation of the role of dietary factors and more
studies including elderly subjects are recommended to
further elucidate the association between SES and
obesity and the contribution of lifestyle factors.
Acknowledgement
The population survey in Va rmland was nanced by
the Va rmland County Council.
References
1. Sobal J, Stunkard J. Socio-economic status and obesi-
ty: A review of the literature. Psychol Bull 1989; 105:
260275.
2. Molarius A, Seidell JC, Sans S, Tuomilehto J, Kuul-
asmaa K for the WHO MONICA Project. Educational
level, relative body weight, and changes in their relation
over 10 years: an international perspective from the
WHO MONICA Project. Am J Public Health 2000; 90:
12601268.
3. Sundquist J, Johansson SE. The inuence of socio-
economic status, ethnicity and lifestyle on body mass
index in a longitudinal study. Int J Epidemiol 1998; 27:
5763.
4. Lahmann PH, Lissner L, Gullberg B, Berglund G.
Sociodemographic factors associated with long-term
weight gain, current body fatness and central adiposity
in Swedish women. Int J Obes 2000; 24: 685694.
5. Lissner L, Johansson SE, Qvist J, Rossner S, Wolk A.
Social mapping of the obesity epidemic in Sweden. Int J
Obes 2000; 24: 801805.
6. Mackenbach JP, Kunst AE, Cavelaars AE, Groenhof
F, Geurts JJM and the EU Working Group on So-
cioeconomic Inequalities in Health. Socioeconomic
inequalities in morbidity and mortality in western Eu-
rope. Lancet 1997; 349: 16551659.
7. Manson JE, Colditz GA, Stampfer MJ, et al. A pro-
spective study of obesity and risk of coronary heart
disease in women. N Engl J Med 1990; 322: 882889.
8. Pi-Sunyer FX. Medical hazards of obesity. Ann Intern
Med 1993; 119: 655660.
9. Jousilahti P, Tuomilehto J, Vartiainen E, Pekkanen J,
Puska P. Body weight, cardiovascular risk factors, and
coronary mortality: 15 year follow-up of middle-aged
men and women in eastern Finland. Circulation 1996;
93: 13721379.
10. Bjo rntorp P. Obesity. Lancet 1997; 350: 423426.
11. Martikainen PT, Marmot MG. Socioeconomic dier-
ences in weight gain and determinants and conse-
quences of coronary risk factors. Am J Clin Nutr 1999;
69: 719726.
12. Seidell JC, Flegal KM. Asessing obesity: Classication
and epidemiology. Br Med Bull 1997; 53: 238252.
13. Lissner L, Heitman BL. Dietary fat and obesity: Evi-
dence from epidemiology. Eur J Clin Nutr 1995; 49:
7990.
14. Molarius A, Seidell JC, Kuulasmaa K, Dobson AJ,
Sans S for the WHO MONICA Project. Smoking and
relative body weight: An international perspective from
the WHO MONICA Project. J Epidemiol Commun
Health 1997; 51: 252260.
15. Tremblay A. Physical activity and obesity. Baillieres
Best Pract Res Clin Endocrinol Metab 1999; 13: 121
129.
16. Wagenknecht LE, Perkins LL, Cutter GR, et al. Cig-
arette smoking behavior is strongly related to educa-
tional status: The Cardia Study. Prev Med 1990; 19:
158169.
17. Pekkanen J, Tuomilehto J, Uutela A, Vartiainen E,
Nissinen A. Social class, health behaviour, and mor-
tality among men and women in eastern Finland. Br
Med J 1995; 311: 589593.
18. Manhem K, Dotevall A, Wilhelmsen L, Rosengren A.
Social gradients in cardiovascular risk factors and
symptoms of Swedish men and women: The Goteborg
MONICA study 1995. J Cardiovasc Risk 2000; 7: 359
368.
19. Jeery RW, French SA, Forster JL, Spry VM. Socio-
economic status dierences in health behaviours related
to obesity: The Healthy Worker Project. Int J Obes
1991; 15: 689696.
20. Jeery RW, French SA. Socioeconomic status and
weight control practises among 20- to 45-year-old
women. Am J Public Health 1996; 86: 10051010.
21. Wamala SP, Wolk A, Orth-Gomer K. Determinants
of obesity in relation to socioeconomic status among
middle-aged Swedish women. Prev Med 1997; 26: 734
744.
22. Obesity Preventing and Managing the Global Epi-
demic. Report of a WHO Consultation on Obesity.
Geneva 35 June 1997. WHO/NUT/NCD/98.1.
23. Heitman BL, Lissner L. Dietary underreporting by
obese individuals is it specic or non-specic? Br Med
J 1995; 311: 986989.
24. Braam LA, Ocke MC, Bueno de Mesquita HB, Seidell
JC. Determinants of obesity-related underreporting of
energy intake. Am J Epidemiol 1998; 147: 10811086.
233
25. Shimakawa T, Sorlie P, Carpenter MA, et al. Dietary
intake pattern and sociodemographic factors in the
atherosclerosis risk in communities study. ARIC Study
Investigators. Prev Med 1994; 23: 769780.
26. Irala-Estevez JD, Groth M, Johansson L, Oltersdorf U,
Prattala R, Martinez-Gonzalez MA. A systematic re-
view of socio-economic dierences in food habits in
Europe: Consumption of fruit and vegetables. Eur J
Clin Nutr 2000; 54: 706714.
27. Lindstro m M, Hanson BS, Brunner E, et al. Socio-
economic dierences in fat intake in a middle-aged
population: Report from the Malmo Diet and Cancer
Study. Int J Epidemiol 2000; 29: 438448.
28. Kromhout D, Bloemberg B, Seidell JC, Nissinen A,
Menotti A. Physical activity and dietary ber determine
population body fat levels: The Seven Countries Study.
Int J Obes 2001; 25: 301306.
29. Eisen SA, Lyons MJ, Goldberg J, True WR. The impact
of cigarette smoking and alcohol consumption on
weight and obesity. An analysis of 1911 monozygotic
male twin pairs. Arch Intern Med 1993; 153: 24572463.
30. Hellerstedt WI, Jeery RW, Murray DM. The associ-
ation between alcohol intake and adiposity in the gen-
eral population. Am J Epidemiol 1990; 132: 594611.
31. Suter PM, Hasler E, Vetter W. Eects of alcohol
on energy metabolism and body weight regulation: Is
alcohol a risk factor for obesity. Nutr Rev 1997; 55:
157171.
32. Rosmond R, Lapidus L, Bjo rntorp P. The inuence of
occupational and social factors on obesity and body fat
distribution in middle-aged men. Int J Obes 1996; 20:
599607.
33. Wardle J, Grith J. Socio-economic status and weight
control practices in British adults. J Epidemiol Com-
mun Health 2001; 55: 185190.
34. Kuskowska-Wolk A, Ro ssner S. The true prevalence
of obesity. Scand J Prim Health Care 1989; 7: 7982.
35. Plankey MW, Stevens J, Flegal KM, Rust PF. Pre-
diction equations do not eliminate systematic error in
self-reported body mass index. Obes Res 1997; 5: 308
314.
36. Ball K, Crawford D, Owen N. Too fat to exercise?
Obesity as a barrier to physical activity. Aust N Z J
Public Health 2000; 24: 331333.
Address for correspondence: A. Molarius, Va stmanland
County Council, Department of Community Medicine, 721
51 Va stera s, Sweden
Phone: 46-21-174583; Fax: 46-21-174515
E-mails: anu.molarius@ltvastmanland.se, anu.molarius@
kau.se
234