Stephanie Klein's diary entry from a "terrible" rainy Tuesday in 1989, when she was 13 years old, included the following rants:
"J.P. never called me back after I called him 4 times!!
"I had to run in gym.
"Some kid called me "moose."
The "moose" insult plagued Klein, now 34, over several years when she was clinically obese. Other girls threw chocolates at her and called her "hot stuff" when she wore a bathing suit. If she won at spin-the-bottle at teen parties, boys would ask for do-overs.
"When I was 8 years old, I was sent to a nutritionist... who told me, 'You will be fat for the rest of your life, even if you look thin,'" Klein said. "Intellectually, I know better, but emotions don't know right from wrong. And it's true across the board for everyone -- the kid with a mole, the fat kid -- however you were ostracized."
Even after she lost weight in high school, made more friends and had more dates, Klein said she hung on to the pain of being the fat kid. The feeling came back whenever she felt rejected.
Studies have shown that children who rank as less popular often have low self-esteem and a poor social support system -- which can translate to poor health outcomes, including depression, drug and alcohol abuse, eating disorders, even suicide.
And the wounds of adolescence can be so deep that they affect a person's physical health long after school days are a distant memory.
Researchers from Sweden found that being unpopular in school increased a person's risk of heart disease and diabetes -- while being popular was linked to good health as an adult. Results from the study were just published in the Journal of Epidemiology and Community Health.
"[Heart disease and diabetes] have not previously been examined in relation to peer status," said Ylva Almquist, a doctoral student at the Center for Health Equity Studies in Stockholm, Sweden, and author of the study. "I think these results further highlight the importance of acknowledging that school is not only about performance and grades, but equally so about the social interplay between children."
The study tracked hospital records from over 14,000 people who were part of the Stockholm Birth Cohort Study that began in 1953. Popularity was measured by asking children, once they reached grade 6 in 1966, to select peers with whom they preferred to work at school. Children were ranked based on how many nominations they received.
Hospital data from 1973-2003 showed that children ranked least popular were nine times more likely to develop heart disease and four times more likely to be treated for diabetes and other hormonal diseases, as well as twice as likely to develop a mental illness.
It was unclear if the stress of being unpopular played a role in disease development, or if popularity was an outward sign of behavioral tendencies that might lead to disease.
Psychologists agree that the study's conclusions make sense, but because of limitations in the study, they warn against making too many assumptions about a link between social standing and health.
Nadine Kaslow, chief psychologist at the Emory University School of Medicine, pointed out that social standings change with age and context. A person may not have many friends at school, for instance, but may be accepted at work or at a summer camp.
Klein, who wrote a book called "Moose: A Memoir of Fat Camp," said she was very popular at the weight loss camps she attended because she was thinner than many other children.
"All of the boys were flocking over," said Klein, adding that she also had her pick of girls to be friends with. "I suddenly felt beautiful and amazing and what a different world that was."
Kaslow also said factors that might contribute to social status -- including support at home, abuse and neglect, and ability to communicate -- are themselves strong indicators of later health outcomes because they influence behavior.
"If you're popular and other kids like you, you feel better about yourself and there's probably more support, so if stresses do happen in life, there are more people to help you deal with it," Kaslow said. "If nobody likes you, you are more likely to hang out or turn to eating bad foods and not take care of yourself."
Almquist said that the results remained consistent even after controlling for socioeconomic status, since that is known to correlate with ill health later in life. She reasoned this was true because, as a young person, social class is filtered through the parents, while social status among peers is a daily battle for many young people, and therefore, has greater impact.
But Dr. William Pollack, psychologist and director of the Center for Men and Young Men at McLean Hospital, pointed out that social class contributes to a person's origin, look and dress, all of which may influence how close peers want to be to a person.
Pollack did say these limitations may have been less important in Sweden in the 1960s than in the U.S. today.
Still, the study may push parents and educators to note how the social environment in a school may affect children and adolescents just as much as the academic environment, Pollack said. He urged adults to help reduce bullying and monitor who may be absent due to illness, complain to teachers, or get in accidents.
"We must be careful about how far one extrapolates [this data]... but there is decent evidence... that how kids rank themselves in middle school can have an effect on emotional well-being and physical well-being that is mediated by behavior years later," Pollack said.
"If we see a child left out, we can't say we don't have to do anything about that because that's how kids are. It makes us think twice."