562555
research-article2014
CPJXXX10.1177/0009922814562555Clinical PediatricsFaus et al
Article
Health-Related Quality of Life in Overweight/Obese Children Compared With Children With Inflammatory Bowel Disease
Clinical Pediatrics 2015, Vol. 54(8) 775–782 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814562555 cpj.sagepub.com
Amy L. Faus, MPH1,2, Renee M. Turchi, MD, MPH2, Marcia Polansky, ScD, MS, MSW2, Andrea Berez, MS, RD, CSP1, and Karen L. Leibowitz, MD1
Abstract Purpose. This study examined the health-related quality of life (HRQOL) of pediatric patients with overweight/ obesity compared with that of patients with inflammatory bowel disease. Methods. Differences between disease groups in their PedsQL 4.0 HRQOL survey scores were analyzed using unpaired t tests and analyses of variance. Results. Scores of patients with overweight/obesity were as low as scores of patients with inflammatory bowel disease. Parent/guardian-proxy social functioning scores of the overweight/obese group were statistically significantly lower than scores of the inflammatory bowel disease group, and the parents/guardians reported significantly lower HRQOL scores than the patients. Conclusions. Overweight/obese children have HRQOL scores as impaired as those of children with inflammatory bowel disease. According to proxy-reported scores, overweight/obesity is associated with lower social functioning. Thus, it is important for health care providers to recognize obesity’s relationship to patients’ psychosocial health and provide holistic care that addresses the severity of this disease. Keywords health-related quality of life, inflammatory bowel disease, obesity, pediatrics
Background Worldwide, more than 40 million children aged 0 to 5 years are overweight or obese.1 The United States reports one of the highest rates of obesity, with 1 in 3 children overweight or obese.2 Recently recognized as a disease by the American Medical Association,3 obesity increases a child’s risk for high blood pressure, high cholesterol, heart disease, type 2 diabetes, sleep apnea, asthma, musculoskeletal problems, fatty liver disease, and some cancers.4 While these physical threats are severe, obesity can also have a serious and immediate impact on a child’s psychological, emotional, and social well-being, leading to low self-esteem, anxiety, and depression.4,5 Health-related quality of life (HRQOL) is a tool used to measure this impact by assessing physical, psychological, and social health.6 This holistic focus is in concordance with the World Health Organization’s definition of health7: “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Studies of HRQOL in adult obese populations8 have demonstrated that obesity has a
negative impact on HRQOL. However, few studies have examined obesity’s impact on HRQOL in children or adolescents. Understanding the effect of obesity on HRQOL compared to other conditions can help health care providers understand its relative clinical impact.9,10 Previous comparative studies have found that HRQOL scores of obese children are similar to those of patients with cancer11 and eosinophilic gastrointestinal disorder,9 and they are even lower than those of patients with diabetes, functional or organic gastrointestinal conditions, cardiac conditions, and asthma.10 While laying a foundation for understanding the severity of childhood obesity’s impact on HRQOL, these studies 1
Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA 2 Drexel University School of Public Health, Philadelphia, PA, USA Corresponding Author: Amy L. Faus, Division of Pediatric Gastroenterology and Nutrition, Rutgers Robert Wood Johnson Medical School, 89 French Street, New Brunswick, NJ 08901, USA. Email: [email protected]
Downloaded from cpj.sagepub.com by guest on November 19, 2015
776
Clinical Pediatrics 54(8)
are limited by their use of secondary data. Whereas such analyses are cost- and time-efficient, biases beyond the authors’ control are introduced by differences in the time of collection, environment, location, collection procedures, coding, and research aims between studies, thus threatening the validity of these studies’ conclusions.12 Only one published study has used primary data to compare HRQOL scores of pediatric patients who are obese to the scores of patients with other chronic conditions. Ravens-Sieberer et al.13 found that HRQOL is more impaired in the pediatric population with obesity than that with asthma/atopic dermatitis. While this result was clear, the generalizability of this conclusion is limited by the lack of consideration in this study of different confounding factors, such as the subjects’ sociodemographic characteristics, which may skew the results. To further our understanding of obesity’s impact on HRQOL in pediatric populations, the current study addressed these limitations by using primary data collection and accounting for confounders, including sociodemographic factors, in the data analysis. Furthermore, a specific chronic gastrointestinal disease, inflammatory bowel disease (IBD), was chosen for comparison with the chronic condition of overweight/obese subjects because of its severity and considerable similarities to obesity. Studies show that IBD has a strong negative impact on HRQOL and can lead to psychosocial concerns similar to those of patients with obesity, including internalizing problems, social withdrawal, depression, avoidance behavior, and fatigue.14-17 Patients with obesity or IBD both deal with acute and chronic symptoms, the threat of future health complications, and stigma related to their condition.18,19 However, because the symptoms of IBD, including abdominal pain, bloody diarrhea, vomiting and weight loss, are particularly severe and often require extensive medical management and use of high-risk medications,20 it was hypothesized that patients with IBD would report lower HRQOL scores than patients with obesity. This direct comparison between HRQOL scores for obesity and IBD patients should advance our understanding of the challenges faced by obese children.
Methods Study Design This study used a cross-sectional design involving the administration of the Pediatric Quality of Life Inventory (PedsQL 4.0) to pediatric patients and their parent/ guardians. The study was approved by the Rutgers University Institutional Review Board.
Sampling The study used a convenience sample that included 120 racially and ethnically diverse male and female pediatric patients, aged 5 to 19 years, who were diagnosed with either overweight/obesity or IBD. Sixty of the patients were overweight/obese, and 60 had a diagnosis of IBD. Each patient’s parent/guardian was also surveyed. Parent/guardians were not present for appointments for several patients aged 18 years and older. In these cases, only patient data were collected. To be included in the study, the overweight/obese subjects had to have a body mass index (BMI) greater than the 85th percentile for children of the same age and sex, and the other disease group had to have a physicianconfirmed diagnosis of IBD. The severity of each IBD subject’s disease was evaluated using the Pediatric Crohn’s Disease Activity Index21 or Pediatric Ulcerative Colitis Activity Index,22 validated standards for the assessment of IBD activity. Subjects were recruited from the Division of Pediatric Gastroenterology and Nutrition at the Rutgers, Robert Wood Johnson Medical School between December 2012 and September 2013. The patient’s parent/guardian signed an informed consent and the patient provided written assent for participation. Patients 18 years and older completed the full informed consent.
Procedures The PedsQL 4.0 child self-report and parent/guardianproxy report scales measure generic HRQOL via 23 items.6 Each item is ranked on a 5-point Likert-type scale (0 = never a problem to 4 = always a problem), and responses are reversed-scored and transformed to a score between 0 and 100, with a higher score indicating better HRQOL. The instrument results in a score for each of four subscales: physical, psychological, social, and school functioning, as well as a total HRQOL score. PedsQL 4.0 has proven to be both valid and reliable (α = .88 for child-report, α = .90 for parent report on total scale score) for subjects as young as 5 years, with agespecific variations in wording for young children, children, adolescents, teens, and young adults.6,10,23 Each patient completed the PedsQL 4.0 form appropriate for his or her age during a visit to the clinic. Concurrently, the patient’s parent/guardian completed the proxy version. Previous research6,11,23-25 has supported the use of parent/guardian-proxy surveying to complement the self-reported HRQOL outcomes of youths, and provide a fuller picture of the health condition’s effect. However, when a parent/guardian was not present for the appointment with patients aged 18 years
Downloaded from cpj.sagepub.com by guest on November 19, 2015
777
Faus et al and older, only the patient format of the PedsQL 4.0 was collected. Information on patient gender, age, BMI, race/ ethnicity, family income, family size, and parent/guardian education, and marital status was collected from patient charts and a brief sociodemographic survey.
confounders. These factors, along with the diagnoses, were entered as independent variables into analyses of variance, with each subscale and total HRQOL score entered as the dependent variable.
Results Data Analysis
Sociodemographics
All data analyses were performed using SPSS 20.0 (IBM Corporation, 2011). Analyses were run on 60 overweight/obese patients and 60 patients with IBD who completed the PedsQL 4.0 survey. In all, 131 of 139 patients invited to participate in the study agreed to do so (94.2%). Two patient/parent dyads declined because of lack of interest, and 6 due to time restraints. Of these 131 subjects, 11 subjects (8.3%) who completed the surveys were excluded from analyses when medical chart review revealed that they fit both disease definitions. Because some patients attended appointments without a parent/guardian, parent-proxy responses for the PedsQL 4.0 were only provided by 50 (83.3%) parent/guardians in the overweight/obesity group, and 53 (88.3%) parent/ guardians in the IBD group. Patient data that was not part of a patient-parent dyad was used for analyses of patient-only responses but was excluded from analyses comparing patient and parent data. Means and standard deviations were calculated for continuous variables, including subject age, BMI, and family size. Percentages by group were calculated for categorical variables, including race/ethnicity, family income, parent/guardian marital status, parent/guardian education, and IBD activity scores. Between diagnosis group differences in these subject characteristics were assessed using unpaired t tests for continuous variables and chi-square analyses for categorical variables. All data were normally distributed. Initial unpaired t tests compared mean patient-reported subscale and total scores on the PedsQL 4.0 between the overweight/obese group and the IBD group. The same tests compared parent/guardian-proxy scores in each group for subscale and total scores. The overall difference between patient and parent/guardian-proxy scores was explored via paired t test. Additionally, the difference between patient and parent-/guardian-reported scores for subscales and total HRQOL was calculated for each patient/parent dyad. The mean difference for each diagnosis group was compared using an unpaired t test. Significance was defined as a P value ≤.05. Patient age, gender, and race/ethnicity, and parent/ guardian education and income, were identified as potential confounders to the relationship between diagnosis and HRQOL scores. Analyses of variance were used to adjust for the potential effect of these
There were statistically significant differences between groups on measures of parent/guardian education and income, and of patient race/ethnicity, age, BMI, and BMI percentile (see Table 1). Differences in BMI were expected, as they represent differences in disease characteristics. Additionally, as shown in Table 1, in the IBD group, 80% of respondents’ conditions were inactive at the time of survey completion, while 20% were experiencing mild symptoms. Disease severity did not correlate significantly with scores on the HRQOL survey. Table 2 shows that gender had a statistically significant impact on patient physical functioning, emotional functioning, psychological summary, physical summary, and total scores. For each of these measures, females in both diagnosis groups reported lower scores than males (mean difference = 6.692, P = .033). However, there was no interaction between gender and diagnosis.
Between–Disease Group Comparisons As shown in Table 2, after adjusting for sociodemographic characteristics, the HRQOL scores of the overweight/obese patients were comparable to those of the IBD patients. Also, the social functioning scores reported by the parent/guardians were significantly lower for the overweight/obese compared with the IBD group (P = .011).
Parent and Patient Perceptions For both diagnoses, parents interpreted their children’s overall quality of life and their physical and emotional functioning more negatively than did their children. Table 3 indicates that mean scores reported by parent/ guardians were statistically significantly lower than those reported by patients for these subscales. The disparity between parent and patient perceptions was comparable in both the overweight/obese and the IBD groups.
Discussion Summary The results of this study demonstrate that the HRQOL scores of patients with overweight/obesity are as
Downloaded from cpj.sagepub.com by guest on November 19, 2015
778
Clinical Pediatrics 54(8)
Sociodemographics
Table 1. Subject Characteristics. Characteristic
Overweight/ Obese
N 60 Family size, people 4.19 (1.39) (mean, SD) Age, years (mean, SD)** 13.15 (3.10) BMI, kg/m2 (mean, SD)** 31.66 (6.95) BMI percentile (mean, 97.25 (3.07) SD)** IBD activity, n (%) Inactive N/A Mild N/A Gender (n, %) Male 28 (46.67) Female 32 (53.33) Parent/guardian’s education (n, %)*
research-article2014
CPJXXX10.1177/0009922814562555Clinical PediatricsFaus et al
Article
Health-Related Quality of Life in Overweight/Obese Children Compared With Children With Inflammatory Bowel Disease
Clinical Pediatrics 2015, Vol. 54(8) 775–782 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814562555 cpj.sagepub.com
Amy L. Faus, MPH1,2, Renee M. Turchi, MD, MPH2, Marcia Polansky, ScD, MS, MSW2, Andrea Berez, MS, RD, CSP1, and Karen L. Leibowitz, MD1
Abstract Purpose. This study examined the health-related quality of life (HRQOL) of pediatric patients with overweight/ obesity compared with that of patients with inflammatory bowel disease. Methods. Differences between disease groups in their PedsQL 4.0 HRQOL survey scores were analyzed using unpaired t tests and analyses of variance. Results. Scores of patients with overweight/obesity were as low as scores of patients with inflammatory bowel disease. Parent/guardian-proxy social functioning scores of the overweight/obese group were statistically significantly lower than scores of the inflammatory bowel disease group, and the parents/guardians reported significantly lower HRQOL scores than the patients. Conclusions. Overweight/obese children have HRQOL scores as impaired as those of children with inflammatory bowel disease. According to proxy-reported scores, overweight/obesity is associated with lower social functioning. Thus, it is important for health care providers to recognize obesity’s relationship to patients’ psychosocial health and provide holistic care that addresses the severity of this disease. Keywords health-related quality of life, inflammatory bowel disease, obesity, pediatrics
Background Worldwide, more than 40 million children aged 0 to 5 years are overweight or obese.1 The United States reports one of the highest rates of obesity, with 1 in 3 children overweight or obese.2 Recently recognized as a disease by the American Medical Association,3 obesity increases a child’s risk for high blood pressure, high cholesterol, heart disease, type 2 diabetes, sleep apnea, asthma, musculoskeletal problems, fatty liver disease, and some cancers.4 While these physical threats are severe, obesity can also have a serious and immediate impact on a child’s psychological, emotional, and social well-being, leading to low self-esteem, anxiety, and depression.4,5 Health-related quality of life (HRQOL) is a tool used to measure this impact by assessing physical, psychological, and social health.6 This holistic focus is in concordance with the World Health Organization’s definition of health7: “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Studies of HRQOL in adult obese populations8 have demonstrated that obesity has a
negative impact on HRQOL. However, few studies have examined obesity’s impact on HRQOL in children or adolescents. Understanding the effect of obesity on HRQOL compared to other conditions can help health care providers understand its relative clinical impact.9,10 Previous comparative studies have found that HRQOL scores of obese children are similar to those of patients with cancer11 and eosinophilic gastrointestinal disorder,9 and they are even lower than those of patients with diabetes, functional or organic gastrointestinal conditions, cardiac conditions, and asthma.10 While laying a foundation for understanding the severity of childhood obesity’s impact on HRQOL, these studies 1
Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA 2 Drexel University School of Public Health, Philadelphia, PA, USA Corresponding Author: Amy L. Faus, Division of Pediatric Gastroenterology and Nutrition, Rutgers Robert Wood Johnson Medical School, 89 French Street, New Brunswick, NJ 08901, USA. Email: [email protected]
Downloaded from cpj.sagepub.com by guest on November 19, 2015
776
Clinical Pediatrics 54(8)
are limited by their use of secondary data. Whereas such analyses are cost- and time-efficient, biases beyond the authors’ control are introduced by differences in the time of collection, environment, location, collection procedures, coding, and research aims between studies, thus threatening the validity of these studies’ conclusions.12 Only one published study has used primary data to compare HRQOL scores of pediatric patients who are obese to the scores of patients with other chronic conditions. Ravens-Sieberer et al.13 found that HRQOL is more impaired in the pediatric population with obesity than that with asthma/atopic dermatitis. While this result was clear, the generalizability of this conclusion is limited by the lack of consideration in this study of different confounding factors, such as the subjects’ sociodemographic characteristics, which may skew the results. To further our understanding of obesity’s impact on HRQOL in pediatric populations, the current study addressed these limitations by using primary data collection and accounting for confounders, including sociodemographic factors, in the data analysis. Furthermore, a specific chronic gastrointestinal disease, inflammatory bowel disease (IBD), was chosen for comparison with the chronic condition of overweight/obese subjects because of its severity and considerable similarities to obesity. Studies show that IBD has a strong negative impact on HRQOL and can lead to psychosocial concerns similar to those of patients with obesity, including internalizing problems, social withdrawal, depression, avoidance behavior, and fatigue.14-17 Patients with obesity or IBD both deal with acute and chronic symptoms, the threat of future health complications, and stigma related to their condition.18,19 However, because the symptoms of IBD, including abdominal pain, bloody diarrhea, vomiting and weight loss, are particularly severe and often require extensive medical management and use of high-risk medications,20 it was hypothesized that patients with IBD would report lower HRQOL scores than patients with obesity. This direct comparison between HRQOL scores for obesity and IBD patients should advance our understanding of the challenges faced by obese children.
Methods Study Design This study used a cross-sectional design involving the administration of the Pediatric Quality of Life Inventory (PedsQL 4.0) to pediatric patients and their parent/ guardians. The study was approved by the Rutgers University Institutional Review Board.
Sampling The study used a convenience sample that included 120 racially and ethnically diverse male and female pediatric patients, aged 5 to 19 years, who were diagnosed with either overweight/obesity or IBD. Sixty of the patients were overweight/obese, and 60 had a diagnosis of IBD. Each patient’s parent/guardian was also surveyed. Parent/guardians were not present for appointments for several patients aged 18 years and older. In these cases, only patient data were collected. To be included in the study, the overweight/obese subjects had to have a body mass index (BMI) greater than the 85th percentile for children of the same age and sex, and the other disease group had to have a physicianconfirmed diagnosis of IBD. The severity of each IBD subject’s disease was evaluated using the Pediatric Crohn’s Disease Activity Index21 or Pediatric Ulcerative Colitis Activity Index,22 validated standards for the assessment of IBD activity. Subjects were recruited from the Division of Pediatric Gastroenterology and Nutrition at the Rutgers, Robert Wood Johnson Medical School between December 2012 and September 2013. The patient’s parent/guardian signed an informed consent and the patient provided written assent for participation. Patients 18 years and older completed the full informed consent.
Procedures The PedsQL 4.0 child self-report and parent/guardianproxy report scales measure generic HRQOL via 23 items.6 Each item is ranked on a 5-point Likert-type scale (0 = never a problem to 4 = always a problem), and responses are reversed-scored and transformed to a score between 0 and 100, with a higher score indicating better HRQOL. The instrument results in a score for each of four subscales: physical, psychological, social, and school functioning, as well as a total HRQOL score. PedsQL 4.0 has proven to be both valid and reliable (α = .88 for child-report, α = .90 for parent report on total scale score) for subjects as young as 5 years, with agespecific variations in wording for young children, children, adolescents, teens, and young adults.6,10,23 Each patient completed the PedsQL 4.0 form appropriate for his or her age during a visit to the clinic. Concurrently, the patient’s parent/guardian completed the proxy version. Previous research6,11,23-25 has supported the use of parent/guardian-proxy surveying to complement the self-reported HRQOL outcomes of youths, and provide a fuller picture of the health condition’s effect. However, when a parent/guardian was not present for the appointment with patients aged 18 years
Downloaded from cpj.sagepub.com by guest on November 19, 2015
777
Faus et al and older, only the patient format of the PedsQL 4.0 was collected. Information on patient gender, age, BMI, race/ ethnicity, family income, family size, and parent/guardian education, and marital status was collected from patient charts and a brief sociodemographic survey.
confounders. These factors, along with the diagnoses, were entered as independent variables into analyses of variance, with each subscale and total HRQOL score entered as the dependent variable.
Results Data Analysis
Sociodemographics
All data analyses were performed using SPSS 20.0 (IBM Corporation, 2011). Analyses were run on 60 overweight/obese patients and 60 patients with IBD who completed the PedsQL 4.0 survey. In all, 131 of 139 patients invited to participate in the study agreed to do so (94.2%). Two patient/parent dyads declined because of lack of interest, and 6 due to time restraints. Of these 131 subjects, 11 subjects (8.3%) who completed the surveys were excluded from analyses when medical chart review revealed that they fit both disease definitions. Because some patients attended appointments without a parent/guardian, parent-proxy responses for the PedsQL 4.0 were only provided by 50 (83.3%) parent/guardians in the overweight/obesity group, and 53 (88.3%) parent/ guardians in the IBD group. Patient data that was not part of a patient-parent dyad was used for analyses of patient-only responses but was excluded from analyses comparing patient and parent data. Means and standard deviations were calculated for continuous variables, including subject age, BMI, and family size. Percentages by group were calculated for categorical variables, including race/ethnicity, family income, parent/guardian marital status, parent/guardian education, and IBD activity scores. Between diagnosis group differences in these subject characteristics were assessed using unpaired t tests for continuous variables and chi-square analyses for categorical variables. All data were normally distributed. Initial unpaired t tests compared mean patient-reported subscale and total scores on the PedsQL 4.0 between the overweight/obese group and the IBD group. The same tests compared parent/guardian-proxy scores in each group for subscale and total scores. The overall difference between patient and parent/guardian-proxy scores was explored via paired t test. Additionally, the difference between patient and parent-/guardian-reported scores for subscales and total HRQOL was calculated for each patient/parent dyad. The mean difference for each diagnosis group was compared using an unpaired t test. Significance was defined as a P value ≤.05. Patient age, gender, and race/ethnicity, and parent/ guardian education and income, were identified as potential confounders to the relationship between diagnosis and HRQOL scores. Analyses of variance were used to adjust for the potential effect of these
There were statistically significant differences between groups on measures of parent/guardian education and income, and of patient race/ethnicity, age, BMI, and BMI percentile (see Table 1). Differences in BMI were expected, as they represent differences in disease characteristics. Additionally, as shown in Table 1, in the IBD group, 80% of respondents’ conditions were inactive at the time of survey completion, while 20% were experiencing mild symptoms. Disease severity did not correlate significantly with scores on the HRQOL survey. Table 2 shows that gender had a statistically significant impact on patient physical functioning, emotional functioning, psychological summary, physical summary, and total scores. For each of these measures, females in both diagnosis groups reported lower scores than males (mean difference = 6.692, P = .033). However, there was no interaction between gender and diagnosis.
Between–Disease Group Comparisons As shown in Table 2, after adjusting for sociodemographic characteristics, the HRQOL scores of the overweight/obese patients were comparable to those of the IBD patients. Also, the social functioning scores reported by the parent/guardians were significantly lower for the overweight/obese compared with the IBD group (P = .011).
Parent and Patient Perceptions For both diagnoses, parents interpreted their children’s overall quality of life and their physical and emotional functioning more negatively than did their children. Table 3 indicates that mean scores reported by parent/ guardians were statistically significantly lower than those reported by patients for these subscales. The disparity between parent and patient perceptions was comparable in both the overweight/obese and the IBD groups.
Discussion Summary The results of this study demonstrate that the HRQOL scores of patients with overweight/obesity are as
Downloaded from cpj.sagepub.com by guest on November 19, 2015
778
Clinical Pediatrics 54(8)
Sociodemographics
Table 1. Subject Characteristics. Characteristic
Overweight/ Obese
N 60 Family size, people 4.19 (1.39) (mean, SD) Age, years (mean, SD)** 13.15 (3.10) BMI, kg/m2 (mean, SD)** 31.66 (6.95) BMI percentile (mean, 97.25 (3.07) SD)** IBD activity, n (%) Inactive N/A Mild N/A Gender (n, %) Male 28 (46.67) Female 32 (53.33) Parent/guardian’s education (n, %)*
