Journal of Pediatric Psychology Advance Access originally published online on May 8, 2007
Journal of Pediatric Psychology 2007 32(7):869-874; doi:10.1093/jpepsy/jsm026
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Brief Report: Quality of Life in Overweight Youth—The Role of Multiple Informants and Perceived Social Support
1Department of Clinical and Health Psychology and 2Department of Pediatrics, University of Florida
All correspondence concerning this article should be addressed to Lisa M. Ingerski, MS, Department of Clinical and Health Psychology, University of Florida, PO Box 100165, Gainesville, FL 32610-0165, USA. lmi{at}phhp.ufl.edu.
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Abstract |
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Objective To examine the impact of overweight status on pediatric quality of life (QOL). Method This correlational study examined the relationship between weight, social support, race, informant, and QOL in a sample of 107 clinically overweight youth, ages 12 to 17 years. Results Regression analysis did not support the relation between QOL and weight. Social support was a significant predictor of youth reports of overall QOL. Males reported better physical QOL than females by both parent and youth report. Paired-samples t-tests supported a discrepancy between child and parent-proxy reports of QOL; parents reported significantly worse QOL than their children across many dimensions. Analysis of variance found no significant difference between Caucasian and African American youth's QOL. Conclusions These results highlighted the importance of considering informant, gender, and the impact of social support when measuring QOL in clinically overweight pediatric populations.
Key words: informant; overweight; quality of life; social support.
Approximately 33% of all youth living in the United States are classified as overweight or at-risk for overweight (Ogden et al., 2006
). While the medical consequences of pediatric overweight status are well documented, the psychological aspects of such status warrant further investigation. Youth overweight status is associated with negative psychological consequences including stigmatization, behavior problems, low self-esteem, body dissatisfaction, and lower perceived physical and cognitive ability (Davison & Birch, 2001; Latner & Stunkard, 2003; Stradmeijer, Bosch, Koops, & Seidell, 2000). Given the continued escalation in rates of overweight and the significant physical and psychological consequences these youth face, understanding the impact of overweight status across all areas of a child's life is vital to comprehensive assessment and treatment.
Quality of life (QOL) instruments provide one method for researchers to measure the impact of pediatric chronic health problems. While individual instruments vary, the majority rely on a multidimensional concept of health that includes both physical and psychosocial dimensions (Eiser & Morse, 2001b). Researchers use generic QOL measures to compare QOL across different disease groups and disease-specific measures to detect differences unique to specific health conditions. Although a thorough description of the methodological issues in QOL measurement goes beyond the scope of this article, previous researchers describe several concerns, including the use of proxies, cognitive development of the child, and measurement format and validity that may impact the use of QOL measures in youth (Matza, Swenson, Flood, Secnik, & Leidy, 2004; Wallander, Schmitt, & Koot, 2001). Despite this debate, researchers using generic measures of QOL have found that QOL is negatively impacted by chronic health problems such as diabetes (Varni et al., 2003) and asthma (Varni, Burwinkle, Rapoff, Kamps, & Olson, 2004). Researchers have also documented a negative relationship between overweight status and QOL (Fallon et al., 2005; Schwimmer, Burwinkle, & Varni, 2003; Swallen, Reither, Haas, & Meier, 2005; Williams, Wake, Hesketh, Maher, & Waters, 2004) such that overweight children report worse QOL. The results of these studies, while suggestive of important differences, are not conclusive. Results vary across studies, dimensions of QOL, QOL measures, and informants. For example, while Schwimmer and colleagues (2003) found that overweight status is related to some dimensions of psychosocial QOL, other researchers found that overweight status is only related to overall and physical health (Swallen et al., 2005).
Examining the impact of different informants, researchers studying QOL in other populations find that parents and children demonstrate greater agreement for observable behaviors than abstract concepts (e.g., peer relationships) and that parents tend to rate their child's QOL lower than does the child (Eiser & Morse, 2001a). Limited research with overweight youth suggests that parents consistently report worse QOL than their children (Schwimmer et al., 2003; Zeller & Modi, 2006). This may be because children lack the cognitive and emotional development to accurately report their QOL, because parents have a limited understanding of their child's internal states and social interactions, or social desirability factors on the part of the children. This finding is not unique to the overweight youth; it is found throughout the pediatric chronic illness literature (Matza et al., 2004; Wallander et al., 2001). Reliance on only one report of QOL may, therefore, not provide a complete picture of the child's QOL. Although both parent proxy and child self-report measures of QOL exist, few researchers recruit multiple informants to measure QOL in overweight populations.
Social support also factors prominently in understanding a child's QOL. Research suggests that overweight youth receive fewer peer friendship nominations than normal weight classmates (Strauss & Pollack, 2003) and that greater emotional support predicts QOL (Ravens-Sieberer, Redegeld, & Bullinger, 2001). Although QOL measures typically include a social functioning component, the limited scope of this dimension does not capture the extent to which peers and parents uniquely contribute to QOL. To the researchers’ knowledge, only one study has examined the impact of family and peer support on overweight youth's QOL (Zeller & Modi, 2006). Although ethnicity is another factor that may affect the QOL of overweight children, research in this area is mixed (Fallon et al., 2005; Schwimmer, et al., 2003; Swallen et al., 2005). Researchers have found some evidence for significant differences between Caucasian and African American children's QOL in an overweight population (Fallon et al., 2005). Moreover, overweight African American youth show lower rates of body dissatisfaction than overweight Caucasian children, which may impact psychosocial functioning and ultimately QOL (Welch, Gross, Bronner, Dewberry-Moore, & Paige, 2004).
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While researchers have documented differences in QOL between overweight youth and their healthy weight peers, few researchers have examined influences on QOL such as informant, ethnicity, or social support. This study of QOL in a strictly at-risk for overweight and overweight pediatric population included three primary aims: (a) to examine the relationship between overweight status, social support, and QOL, (b) to investigate the discrepancy between youth and parent-proxy report of child's QOL, and (c) to explore differences in QOL between Caucasian and African American youth. The researchers hypothesized that (a) weight and social support would significantly predict QOL; specifically, that degree of overweight would predict QOL and that youth reporting higher social support would also report higher QOL, (b) a discrepancy would exist between youth and parent report of QOL such that parents report worse QOL, and (c) a significant difference would exist between Caucasian and African American youth's reported QOL such that African American youth would report higher QOL.
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Methods |
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Participants
The current study included 107 youth (46% male, 54% female) aged 12 to 17 years (M = 13.50, SD = 1.38), ranging from fifth to twelfth grade (M = 7.95, SD = 1.70). Of the participants, 101 youth were overweight (
95th percentile) and 6 youth were at-risk for overweight (>85th percentile and <95th percentile) based on national norms from the Centers for Disease Control (Kuczmarski et al., 2000). Youth were predominantly Caucasian (56% Caucasian, 25% African American, 5% Hispanic, 5% Native American, 9% other racial minority, and 1% unknown). Legal guardians were primarily mothers (83% mothers, 8% fathers, and 8% other legal guardians) and married (59% married, 39% single, and 2% unknown). The median family income ranged from 20,000 to 40,000 dollars per year. Inclusion criteria required that the youth (a) be overweight or at risk for overweight, (b) be between the ages of 12 and 17 years old, and (c) be accompanied by a legal guardian. Exclusion criteria included being diagnosed as mentally retarded or having a psychotic disorder.
Procedure
A research team member recruited potential participants from an out-patient obesity clinic. Participants independently completed questionnaires in the waiting room or examination room. Completion of questionnaires took approximately 30 min and the family received modest compensation. The governing Institutional Review Board approved the research protocol.
Measures
The measures included in the current study were part of a larger project investigating barriers to healthy lifestyle recommendations experienced by overweight youth.
Anthropometrics
Clinic medical staff measured children's height and weight as part of their routine medical examination.
Demographic Questionnaire
The participating child's parent or legal guardian completed a 13-item questionnaire covering general demographic information.
Pediatric Quality of Life Inventory (PedsQL)
Children and parents each completed age-appropriate versions of the PedsQL, a well-established instrument assessing physical and psychosocial dimensions of QOL. The measure yielded three summary scores: a Psychosocial Health Summary Score, a Physical Health Summary Score, and a Total Scale Score. These scores have demonstrated good reliability and validity in pediatric populations (Varni, Burwinkle, Seid, & Skarr, 2003; Varni, Seid, & Kurtin, 2001).
Multidimensional Scale of Perceived Social Support (MSPSS)
Youth completed the friend and family subscales of the MSPSS (eight items), a self-report measure of perceived social support. The MSPSS has demonstrated good psychometric properties and has been used reliably in both adult and adolescent populations (Canty-Mitchell & Zimet, 2000; Chou, 2000; Zimet, Powell, Farley, Werkman, & Berkoff, 1990).
Statistical Analyses
The researchers conducted descriptive statistics and correlations across variables of interest. Using the method described by Pinhas-Hamiel and colleagues (2006), BMI was converted to a z-score using the mean BMI and standard deviation by age and gender from national normative data (Rosner, Prineas, Loggie, & Daniels, 1998). Paired-sample t-tests compared differences between child and parent reports of child QOL. Ethnicity was re-coded as a dichotomous variable for regression analysis: minority (African American, Hispanic, Native American, other; n = 46) or nonminority (Caucasian; n = 60). Separate hierarchical regressions tested the hypothesis that the weight and perceived social support significantly predict QOL. The first block of the model included demographic variables (age, gender, and ethnicity); the second block of the model included BMI z-score and total social support score. Youth and parent reported QOL (total score, psychosocial, and physical health summary scores) were individually entered as the dependent variable in separate regression equations. Two ANOVAs tested for differences between Caucasian and African American youth's QOL for parent and youth report. Ethnicity was re-coded as a dichotomous variable, African American (n = 27) or Caucasian, and children of other ethnicities were excluded from ANOVA analyses.
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Results |
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Table I shows descriptive statistics and correlations among variables. Paired-sample t-tests (Table II) found that youth reported significantly better QOL than their parents on the following dimensions: total score (t = 5.06, p < .001), psychosocial (t = 3.19, p < .01), and physical (t = 6.18, p < .001) functioning summary scores, and physical (t = 6.18, p < .001) and social (t = 3.90, p < .001) functioning subscales. No significant discrepancy existed between youth and parent reported QOL on the school (t = 1.85, p = .07) and emotional (t = .58, p = .57) functioning subscales.
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Contrary to the researchers’ expectations, BMI z-score was not a significant predictor of youth or parent reported QOL. The total model predicting parent reported overall QOL was not significant (R2 = .07, p = .23). However, the total model predicting youth reported overall QOL accounted for 13% of the variance in overall QOL (R2 = .13, p < .05) and revealed a main effect for total social support (ß = .28, p < .01) such that youth reporting higher social support reported higher QOL. Given the main effect of total social support, the researchers conducted post hoc analyses entering family and friend social support separately into the model to predict youth reported total QOL and physical summary scores. Neither model was significant.
Secondary analysis found no significant relationship between the above variables and youth (R2 = .09, p = .12) and parent (R2 = .03, p = .68) reported psychosocial health summary scores. In contrast, the model significantly predicted both youth (R2 = .17, p < .01) and parent (R2 = .12, p < .05) reported physical health summary scores. Regression analyses revealed a main effect for gender by both youth (ß = –.28, p < .01) and parent (ß = –.26, p < .05) report. Males reported better physical QOL than females.
Examining only Caucasian and African American youth, separate ANOVAs found no significant difference between African American and Caucasian youth's reported QOL for either the child or parent proxy report across the total and summary scores.
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Discussion |
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The current study added to existing literature by examining a more racially diverse sample that includes parent and youth report and how different sources of social support influence QOL. Comparison of this data to published data revealed that youth reported QOL in this study (M = 73.8) is lower than that reported by healthy children (M = 83.0; Varni et al., 2001
) but higher than that reported by overweight adolescents (M = 67.0; Schwimmer et al., 2003). Parent-proxy report of QOL (M = 65.7) showed a similar pattern of results between previously reported healthy (M = 87.6) and overweight (M = 63.3) participants. Unlike previous research with overweight children (Schwimmer et al., 2003; Zeller & Modi, 2006), this study found that the degree of overweight (as measured by BMI z-score) was not related to QOL.
The current data supported a relationship between gender and physical QOL in overweight youth. Similar to other findings in the area (Swallen et al., 2005), the current study found that adolescent males reported better physical QOL than females. This finding differed from Schwimmer and colleagues (2003) who found no significant gender effects in their sample of youth, aged 5–18 years. Perhaps, differences between male and female reports of QOL do not emerge until later in adolescence, which may be due to higher physical self-esteem in overweight males compared to overweight adolescent females (Strauss, 2000). Similar to previous findings (Schwimmer et al., 2003), the data supported the hypothesis that significant differences exist between child and parent proxy reports of child QOL. As hypothesized, the current study documented significant differences in youth and parent reports of QOL across several dimensions. However, the finding of a significant difference between youth and parent reports on the physical health dimension, but not on the social or emotional dimensions, was surprising. Previous research suggests that parents and youth tend to show greater agreement for observable behaviors than internal states (Matza et al., 2004). Given the positive relationship between social support and QOL in the population, perhaps youth in this sample were more likely to talk to their parents about what they were thinking and feeling. Although it is unclear why parents reported lower QOL than their children, it is apparent that researchers should use multiple informants whenever possible to obtain the most accurate picture of youth's QOL.
This study extends the findings by Zeller and Modi (2006) who reported that that higher self-reported social support was related to higher self-reported overall and physical QOL. Taken together, these studies suggest that social support is especially important to youth's QOL. Given previous knowledge regarding peer victimization and self-esteem in this population, interventions aimed toward enhancing overweight youth's peer group may be critical. This finding also supports the Center for Disease Control's (1996) recommendation to include social support as a component in youth health programs. Finally, in contrast to Fallon and colleagues (2005) who found that African American youth reported better QOL than Caucasian youth across many dimensions, the current study found no evidence of differences between African American and Caucasian children's QOL. This finding may be due, in part, to the different measures utilized in the two studies. In addition, Fallon and colleagues utilized an obesity-specific measure of QOL that may have been better able to detect differences by ethnicity.
One limitation of this study is the small sample size. The external validity of this sample must also be considered with discretion given that participants were all at-risk and overweight youth presenting for treatment. The correlational nature of the current study limits the conclusions drawn. Longitudinal research examining the impact of overweight status on youth may help further clarify the relationship between weight and QOL. The current study employs a generic measure of QOL, the PedsQL. Studies using other generic measures of QOL may not replicate the current findings. In addition, this generic measure of QOL may lack the sensitivity to detect differences in QOL in an exclusively overweight sample. Future research using an overweight-specific measure of QOL may allow researchers to examine unique aspects of QOL associated with being overweight. Despite these limitations, the value of QOL measurement in studying the unique health perspectives of overweight youth is unmistakable. QOL measurement in overweight populations offers both researchers and clinicians an integrative method to quantify the impact that overweight status has across a variety of different dimensions as well as how different factors influence QOL in this population.
Conflict of interest: None declared.
Received February 20, 2006; revision received March 5, 2007; accepted March 26, 2007
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