RESEARCH ARTICLE
The Role of Social Support for Promoting Quality of Life Among Persistently Obese Adolescents: Importance of Support in Schools YELENA P. WU, PhDa JENNIFER REITER-PURTILL, PhDb MEG H. ZELLER, PhDc
ABSTRACT BACKGROUND: Despite school-based and other interventions for pediatric obesity, many obese youth of the present generation will persist in their obesity into adolescence and adulthood. Thus, understanding not only how better to tailor weight interventions but how to promote overall adjustment for persistently obese youth is of utmost importance. This study examined the role of perceived social support in predicting later psychosocial status (ie, weight-related quality of life) for persistently obese adolescents. METHODS: This study used a longitudinal design whereby persistently obese and nonoverweight comparison youth completed measures at 2 time points approximately 4 years apart. RESULTS: Obese youth reported lower levels of social support than comparison youth. Among obese youth, classmate and teacher support predicted future weight-related quality of life. CONCLUSIONS: Social support, particularly from classmates, is an important predictor for the longitudinal psychosocial functioning of persistently obese youth. High levels of perceived teacher support may signal the presence of other psychosocial difficulties. Implications for school-based interventions are discussed. Keywords: obesity; longitudinal; social support; quality of life; school-based intervention. Citation: Wu YP, Reiter-Purtill J, Zeller MH. The role of social support for promoting quality of life among persistently obese adolescents: importance of support in schools. J Sch Health. 2014; 84: 99-105. Received on January 11, 2012 Accepted on December 2, 2012
A
lthough the incidence of pediatric obesity has slowed, 16.9% of children 2 to 19 years of age in the United States are currently obese (≥95th percentile for body mass index [BMI]).1 A substantial literature has documented not only the physical but also the psychosocial consequences of obesity, including peer-based difficulties and health-related quality of life (HRQOL) impairment.2-4 Accordingly, there has been a keen interest in providing interventions that prevent the development of pediatric obesity or improve weight-related health in obese youth.5 Schools have been cited as an important and ideal setting in which
interventions should be provided.6,7 School-based obesity interventions primarily target increasing relevant knowledge (eg, principles of healthy eating) and enacting behavior change (eg, increasing physical activity, modifying eating practices), and have demonstrated different levels of effectiveness.6,7 However, despite school-based and other behavioral and medical intervention efforts to decrease BMI and improve health outcomes, the overwhelming majority of obese youth of the present generation will persist in their obesity in adolescence and into adulthood.5,8 It is these youth who are at highest risk for poor long-term outcomes.8
a Assistant Professor,
([email protected]), Division of Public Health Department of Family and Preventive Medicine, Huntsman Cancer Institute University of Utah, 375 Chipeta Way, Suite A Salt Lake City, UT 84108. b Research Associate, ([email protected]), Division of Behavioral Medicine & Clinical Psychology, MLC 3015, 3333 Burnet Avenue, Cincinnati, OH 45229. c Associate Professor, ([email protected]), Division of Behavioral Medicine & Clinical Psychology, MLC 3015, 3333 Burnet Avenue, Cincinnati, OH 45229. Address correspondence to: Yelena P. Wu, Assistant Professor, ([email protected]), Division of Public Health Department of Family and Preventive Medicine, Huntsman Cancer Institute University of Utah, 375 Chipeta Way, Suite A Salt Lake City, UT 84108. This research was funded by a grant from the National Institutes of Health (K23 DK60031) and the Cincinnati Children’s Hospital Research Foundation awarded to M.H.Z.
Journal of School Health
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February 2014, Vol. 84, No. 2
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© 2014, American School Health Association • 99
Thus, it is essential to improve understanding of how we can promote the overall adjustment of persistently obese youth over time, particularly in the settings where youth spend the most time (eg, school). One indicator of adjustment among obese youth is HRQOL, the impact a health condition has on functioning across multiple domains (ie, physical, emotional, social, academic/ job). Within the HRQOL literature, conditionspecific measures (eg, weight-related quality of life [WRQOL]) have increasingly been used to more closely examine how unique aspects of health conditions impact functioning.9 For example, WRQOL captures how day-to-day functioning is challenged by excess weight, such as in one’s social and physical functioning, and body esteem (ie, how an obese youth feels about his/her body). For obese youth, WRQOL includes understanding the extent to which weight makes it hard to fit in public seats or to buy clothing, or negatively impacts their self-confidence and ability to make friends. Although prior research has suggested that obese youth experience significant HRQOL and WRQOL impairments when compared with non-obese youth and youth with other pediatric chronic medical conditions,10,11 we lack an understanding of whether there are psychosocial factors that may be modifiable through intervention which in turn result in improved outcomes (eg, WRQOL) for youth who persist in their obesity over time. Perceived social support, an individual’s cognitive appraisal regarding the availability of significant others in their social network to provide support,12 is one potentially modifiable factor. Perceived social support has been associated with decreased levels of distress and increased adaptive health behaviors in youth with other chronic health conditions,13,14 and therefore, may be a particularly important predictor of weight-related outcomes. Indeed, prior findings indicate that social influences (ie, school, peers, parents) are related to adolescent’s weight-related health practices15 and a small literature provides initial evidence of a concurrent (eg, cross-sectional) link between higher perceived social support (eg, from classmates, total support) and greater physical and social HRQOL/WRQOL for obese youth.16-18 However, to date, it remains unknown whether social support plays a protective role in longer-term psychosocial outcomes for youth whose obesity persists over time. When examining social support, it is also important to consider the different sources (eg, teachers, parents, classmates, close friends) as they may play unique roles and vary in perceived importance at different points in development.19 For instance, given the well-documented peer difficulties (eg, low peer acceptance, victimization, stigmatization) experienced by obese youth,20-22 it might be expected that obese youth would experience less support from peers 100
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Journal of School Health
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February 2014, Vol. 84, No. 2 •
than non-overweight youth. This may be especially troubling during adolescence, a time when youth are increasingly focused on self-image, appearance, and peer relationships.23 Furthermore, because certain sources of social support (eg, teachers, peers, classmates) are likely salient in the school setting, the examination of perceived support from these different sources may be particularly relevant for school professionals and inform school-based efforts to promote the well-being of obese students. Research Questions and Purpose of Study This study aims to advance the literature by examining whether perceived social support varies over time and is predictive of later psychosocial status (ie, WRQOL) for youth who persist in their obesity. Specifically, utilizing a longitudinal design, youth who persisted in their obesity were assessed at 2 time points (T1 and T2), approximately 4 years apart. The study design is enhanced by the inclusion of a persistently nonoverweight, demographically similar comparison group followed over the same course of time. On the basis of the extant cross-sectional literature, we hypothesized that persistently obese youth would report lower levels of social support at both time points relative to comparison peers, as well as experience decreasing social support over time. Within the obese group, we hypothesized that higher perceived social support at T1 would predict higher WRQOL at T2, and we explored the role that different sources of social support (ie, from teachers, classmates, close friends, and parents) played in predicting WRQOL.
METHODS Participants Obese participants were recruited from a pediatric hospital outpatient weight management program for children with BMI ≥ 95th percentile for age and sex. Youth were eligible to participate at T1 if they were 8 to 16 years of age, did not receive full-time special education or homeschooling, lived within 60 mi of the hospital, and had no genetic syndromes for which obesity was a comorbidity. Following a classroom-based evaluation of peer relationships,22 86 obese youth and caregivers completed the T1 assessment (caregiver data is not presented in this manuscript), and approximately 4 years later, were asked to complete a T2 assessment if youth were not over the age of 19 (or had not yet graduated from high school or enrolled in post-high school education). At T2, 59 obese youth participated (6 declined, 19 ineligible due to age, 1 youth had died, 1 had a parent with a serious illness). During the initial classroom study, a list was made of potential comparison classmates of the same sex and
© 2014, American School Health Association
race as the obese youth who were visually assessed as non-overweight.22 The family of the youth closest in date of birth to the obese participant was recruited via phone by a research assistant for participation in the T1 study. If they declined, the family of the youth whose birthday was next closest was called. Seventy percent of participating comparison youth were first choices. Anthropometric measurements were used at T1 and T2 to determine whether comparison youth had BMIs between the 5th and 85th percentile. At T1, 74 comparison youth participated, and at T2, 42 comparison youth participated (19 ineligible due to age, 14 declined). Given this study’s aim to examine outcomes for youth who persist in obesity, the current analysis included only those youth who maintained their weight status across time points (91% of obese youth and 80% of comparisons completing T2) and who had a participating female caregiver. After applying the inclusion criteria, 53 treatment-seeking obese youth and 32 comparison youth were included in the present analysis. Female caregivers were predominantly mothers (N = 79, 93%). Obese and comparison youth were similar on all demographic characteristics (Table 1) except that obese youth were of significantly lower family socioeconomic status (SES) than comparison youth [t(83) = −2.64, p = .01]. Thus, SES was controlled for in group comparison analyses. Attrition analyses comparing youth who participated at both time points (‘‘longitudinal participants’’) versus those who participated at T1 only indicated that longitudinal participants were significantly younger (r = −.48, p < .001), which was expected given the age exclusion criteria at T2. In addition, girls were more likely to complete T1 only (χ 2 = 4.8 (1, N = 143), p < .05). No group differences were identified on mean levels of total social support. Time between assessments (R = 2.4 to 6.0 years) was not related to social support or HRQOL, and thus, was not controlled for. Table 1. Mean Group Demographics (SD Unless Otherwise Noted)
T1 Child zBMI T2 Child zBMI T2 Child Age (Years) T2 Family SES∗ Child’s Sex (Female) Child’s Race White African American Biracial T2 Single-Parent Families Years between T1 & T2
Obese (N = 53)
Comparison (N = 32)
2.4 (0.3) 2.5 (0.4) 15.6 (1.5) 42.1 (22.6) 53%
−0.19 (0.7) −0.04 (0.8) 15.8 (1.2) 53.5 (23.0) 47%
45% 47% 8% 56% 4.2 (0.8)
59% 38% 3% 38% 4.2 (.9)
p
The Role of Social Support for Promoting Quality of Life Among Persistently Obese Adolescents: Importance of Support in Schools YELENA P. WU, PhDa JENNIFER REITER-PURTILL, PhDb MEG H. ZELLER, PhDc
ABSTRACT BACKGROUND: Despite school-based and other interventions for pediatric obesity, many obese youth of the present generation will persist in their obesity into adolescence and adulthood. Thus, understanding not only how better to tailor weight interventions but how to promote overall adjustment for persistently obese youth is of utmost importance. This study examined the role of perceived social support in predicting later psychosocial status (ie, weight-related quality of life) for persistently obese adolescents. METHODS: This study used a longitudinal design whereby persistently obese and nonoverweight comparison youth completed measures at 2 time points approximately 4 years apart. RESULTS: Obese youth reported lower levels of social support than comparison youth. Among obese youth, classmate and teacher support predicted future weight-related quality of life. CONCLUSIONS: Social support, particularly from classmates, is an important predictor for the longitudinal psychosocial functioning of persistently obese youth. High levels of perceived teacher support may signal the presence of other psychosocial difficulties. Implications for school-based interventions are discussed. Keywords: obesity; longitudinal; social support; quality of life; school-based intervention. Citation: Wu YP, Reiter-Purtill J, Zeller MH. The role of social support for promoting quality of life among persistently obese adolescents: importance of support in schools. J Sch Health. 2014; 84: 99-105. Received on January 11, 2012 Accepted on December 2, 2012
A
lthough the incidence of pediatric obesity has slowed, 16.9% of children 2 to 19 years of age in the United States are currently obese (≥95th percentile for body mass index [BMI]).1 A substantial literature has documented not only the physical but also the psychosocial consequences of obesity, including peer-based difficulties and health-related quality of life (HRQOL) impairment.2-4 Accordingly, there has been a keen interest in providing interventions that prevent the development of pediatric obesity or improve weight-related health in obese youth.5 Schools have been cited as an important and ideal setting in which
interventions should be provided.6,7 School-based obesity interventions primarily target increasing relevant knowledge (eg, principles of healthy eating) and enacting behavior change (eg, increasing physical activity, modifying eating practices), and have demonstrated different levels of effectiveness.6,7 However, despite school-based and other behavioral and medical intervention efforts to decrease BMI and improve health outcomes, the overwhelming majority of obese youth of the present generation will persist in their obesity in adolescence and into adulthood.5,8 It is these youth who are at highest risk for poor long-term outcomes.8
a Assistant Professor,
([email protected]), Division of Public Health Department of Family and Preventive Medicine, Huntsman Cancer Institute University of Utah, 375 Chipeta Way, Suite A Salt Lake City, UT 84108. b Research Associate, ([email protected]), Division of Behavioral Medicine & Clinical Psychology, MLC 3015, 3333 Burnet Avenue, Cincinnati, OH 45229. c Associate Professor, ([email protected]), Division of Behavioral Medicine & Clinical Psychology, MLC 3015, 3333 Burnet Avenue, Cincinnati, OH 45229. Address correspondence to: Yelena P. Wu, Assistant Professor, ([email protected]), Division of Public Health Department of Family and Preventive Medicine, Huntsman Cancer Institute University of Utah, 375 Chipeta Way, Suite A Salt Lake City, UT 84108. This research was funded by a grant from the National Institutes of Health (K23 DK60031) and the Cincinnati Children’s Hospital Research Foundation awarded to M.H.Z.
Journal of School Health
•
February 2014, Vol. 84, No. 2
•
© 2014, American School Health Association • 99
Thus, it is essential to improve understanding of how we can promote the overall adjustment of persistently obese youth over time, particularly in the settings where youth spend the most time (eg, school). One indicator of adjustment among obese youth is HRQOL, the impact a health condition has on functioning across multiple domains (ie, physical, emotional, social, academic/ job). Within the HRQOL literature, conditionspecific measures (eg, weight-related quality of life [WRQOL]) have increasingly been used to more closely examine how unique aspects of health conditions impact functioning.9 For example, WRQOL captures how day-to-day functioning is challenged by excess weight, such as in one’s social and physical functioning, and body esteem (ie, how an obese youth feels about his/her body). For obese youth, WRQOL includes understanding the extent to which weight makes it hard to fit in public seats or to buy clothing, or negatively impacts their self-confidence and ability to make friends. Although prior research has suggested that obese youth experience significant HRQOL and WRQOL impairments when compared with non-obese youth and youth with other pediatric chronic medical conditions,10,11 we lack an understanding of whether there are psychosocial factors that may be modifiable through intervention which in turn result in improved outcomes (eg, WRQOL) for youth who persist in their obesity over time. Perceived social support, an individual’s cognitive appraisal regarding the availability of significant others in their social network to provide support,12 is one potentially modifiable factor. Perceived social support has been associated with decreased levels of distress and increased adaptive health behaviors in youth with other chronic health conditions,13,14 and therefore, may be a particularly important predictor of weight-related outcomes. Indeed, prior findings indicate that social influences (ie, school, peers, parents) are related to adolescent’s weight-related health practices15 and a small literature provides initial evidence of a concurrent (eg, cross-sectional) link between higher perceived social support (eg, from classmates, total support) and greater physical and social HRQOL/WRQOL for obese youth.16-18 However, to date, it remains unknown whether social support plays a protective role in longer-term psychosocial outcomes for youth whose obesity persists over time. When examining social support, it is also important to consider the different sources (eg, teachers, parents, classmates, close friends) as they may play unique roles and vary in perceived importance at different points in development.19 For instance, given the well-documented peer difficulties (eg, low peer acceptance, victimization, stigmatization) experienced by obese youth,20-22 it might be expected that obese youth would experience less support from peers 100
•
Journal of School Health
•
February 2014, Vol. 84, No. 2 •
than non-overweight youth. This may be especially troubling during adolescence, a time when youth are increasingly focused on self-image, appearance, and peer relationships.23 Furthermore, because certain sources of social support (eg, teachers, peers, classmates) are likely salient in the school setting, the examination of perceived support from these different sources may be particularly relevant for school professionals and inform school-based efforts to promote the well-being of obese students. Research Questions and Purpose of Study This study aims to advance the literature by examining whether perceived social support varies over time and is predictive of later psychosocial status (ie, WRQOL) for youth who persist in their obesity. Specifically, utilizing a longitudinal design, youth who persisted in their obesity were assessed at 2 time points (T1 and T2), approximately 4 years apart. The study design is enhanced by the inclusion of a persistently nonoverweight, demographically similar comparison group followed over the same course of time. On the basis of the extant cross-sectional literature, we hypothesized that persistently obese youth would report lower levels of social support at both time points relative to comparison peers, as well as experience decreasing social support over time. Within the obese group, we hypothesized that higher perceived social support at T1 would predict higher WRQOL at T2, and we explored the role that different sources of social support (ie, from teachers, classmates, close friends, and parents) played in predicting WRQOL.
METHODS Participants Obese participants were recruited from a pediatric hospital outpatient weight management program for children with BMI ≥ 95th percentile for age and sex. Youth were eligible to participate at T1 if they were 8 to 16 years of age, did not receive full-time special education or homeschooling, lived within 60 mi of the hospital, and had no genetic syndromes for which obesity was a comorbidity. Following a classroom-based evaluation of peer relationships,22 86 obese youth and caregivers completed the T1 assessment (caregiver data is not presented in this manuscript), and approximately 4 years later, were asked to complete a T2 assessment if youth were not over the age of 19 (or had not yet graduated from high school or enrolled in post-high school education). At T2, 59 obese youth participated (6 declined, 19 ineligible due to age, 1 youth had died, 1 had a parent with a serious illness). During the initial classroom study, a list was made of potential comparison classmates of the same sex and
© 2014, American School Health Association
race as the obese youth who were visually assessed as non-overweight.22 The family of the youth closest in date of birth to the obese participant was recruited via phone by a research assistant for participation in the T1 study. If they declined, the family of the youth whose birthday was next closest was called. Seventy percent of participating comparison youth were first choices. Anthropometric measurements were used at T1 and T2 to determine whether comparison youth had BMIs between the 5th and 85th percentile. At T1, 74 comparison youth participated, and at T2, 42 comparison youth participated (19 ineligible due to age, 14 declined). Given this study’s aim to examine outcomes for youth who persist in obesity, the current analysis included only those youth who maintained their weight status across time points (91% of obese youth and 80% of comparisons completing T2) and who had a participating female caregiver. After applying the inclusion criteria, 53 treatment-seeking obese youth and 32 comparison youth were included in the present analysis. Female caregivers were predominantly mothers (N = 79, 93%). Obese and comparison youth were similar on all demographic characteristics (Table 1) except that obese youth were of significantly lower family socioeconomic status (SES) than comparison youth [t(83) = −2.64, p = .01]. Thus, SES was controlled for in group comparison analyses. Attrition analyses comparing youth who participated at both time points (‘‘longitudinal participants’’) versus those who participated at T1 only indicated that longitudinal participants were significantly younger (r = −.48, p < .001), which was expected given the age exclusion criteria at T2. In addition, girls were more likely to complete T1 only (χ 2 = 4.8 (1, N = 143), p < .05). No group differences were identified on mean levels of total social support. Time between assessments (R = 2.4 to 6.0 years) was not related to social support or HRQOL, and thus, was not controlled for. Table 1. Mean Group Demographics (SD Unless Otherwise Noted)
T1 Child zBMI T2 Child zBMI T2 Child Age (Years) T2 Family SES∗ Child’s Sex (Female) Child’s Race White African American Biracial T2 Single-Parent Families Years between T1 & T2
Obese (N = 53)
Comparison (N = 32)
2.4 (0.3) 2.5 (0.4) 15.6 (1.5) 42.1 (22.6) 53%
−0.19 (0.7) −0.04 (0.8) 15.8 (1.2) 53.5 (23.0) 47%
45% 47% 8% 56% 4.2 (0.8)
59% 38% 3% 38% 4.2 (.9)
p
