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Editorial

See Corresponding Article by Kolotkin et al. on pages 748 –756

Health-Related Quality of Life among Obese Subgroups Kevin R. Fontaine

Although the medical consequences of obesity are, quite rightly, the central focus of both obesity researchers and clinicians, it has increasingly become clear that the problems associated with obesity are not restricted simply to its effect on health; obesity also has a substantial impact on a person’s health-related quality of life (HRQOL). HRQOL is generally regarded as a multidimensional construct encompassing emotional, physical, and social domains that reflect an individual’s subjective evaluation and reaction to a health condition (1). Studies using both generic and obesity-specific measures of HRQOL have established that obesity is associated with profound decreases in HRQOL and that the greatest impairment tends to be on physically oriented domains of functioning (2,3). It has also been observed that the degree of HRQOL impairment tends to correspond with the level of obesity; heavier people report the greatest HRQOL impairment. Because the majority of obesity-related HRQOL studies have been conducted with individuals seeking treatment for their weight, typically university-based obesity treatment, it remains unknown whether the HRQOL among obese individuals who do not seek treatment differs markedly from those who do seek treatment. It is also unknown whether HRQOL differs among individuals with obesity seeking different forms of obesity treatment (e.g., outpatient treatment or gastric bypass). In this issue of Obesity Research, Kolotkin et al. (4) address these important questions by measuring obesityspecific HRQOL using the Impact of Weight on Quality of Life-Lite questionnaire (IWQOL-Lite) in a large (n ⫽ 3353) geographically and demographically diverse sample of overweight and obese adults who either were or were not seeking obesity treatment. Moreover, among those seeking treatment, the authors were able to capture

Received for review May 15, 2002. Accepted in final form May 18, 2002. Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland. Address correspondence to Kevin R. Fontaine, Ph.D., 5501 Hopkins Bayview Circle, Room 3B.35, Baltimore, MD 21224. E-mail: [email protected] Copyright © 2002 NAASO

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the HRQOL of individuals along the range of obesitytreatment options from the least intensive (clinical trial involving infrequent meetings) to most intensive (gastric bypass surgery). Thus, this design allowed the authors to evaluate the continuum of available obesity treatments, as well as evaluate and compare HRQOL as a function of whether or not treatment was sought. Results indicated that, after controlling for age and body mass index, obesity-specific HRQOL was significantly more impaired according to the self-esteem, sexual life, work scales, and the IWQOL-Lite total score among treatment seekers compared with overweight/obese adults not currently seeking obesity treatment. Moreover, within treatment seekers, the degree of HRQOL impairment varied by treatment intensity. That is, the greatest level of impairment was found among gastric bypass patients, whereas the least HRQOL impairment was found among clinical-trial participants. Supplementary analyses indicated that greater HRQOL impairment was reported by whites, as well as by individuals with higher body mass indices, and by women in the non-treatment and clinical-trial groups. Although, in my view, this is a definitive study with regard to estimating the HRQOL of individuals with obesity, the non-treatment-seeking group of overweight and obese adults was not randomly selected, raising the possibility that their responses may not have been representative of the population of non-treatment-seeking individuals with obesity. Despite this possibility, the study by Kolotkin et al. (4) adds significantly to our knowledge by suggesting that the degree of HRQOL impairment corresponds with the intensity of the obesity treatment sought. Although we cannot determine from this study the role HRQOL played in a person’s decision regarding whether or not to seek treatment or what type of treatment to seek, it is not unreasonable to propose that perceptions of HRQOL are important determinants of not only whether obese individuals seek treatment, but also the type of treatment they choose. The findings of Kolotkin et al. (4) imply that it may be both possible and worthwhile to use HRQOL assessments in a proactive way to assist obese individuals in making decisions about how to best manage their weight. That is,

Editorial, Fontaine

discussing the results of a HRQOL assessment with obese patients can stimulate a conversation that focuses explicitly on the impact their body weight has had on the way they live their life. Because body weight is generally gained slowly, many obese patients are not aware of the influence their weight has had on important dimensions until specific attention is given. Examining the impact of weight on these dimensions will allow clinicians to personalize the potential benefits that can be conferred from obesity treatment, as well as to help in the exploration of treatment options. For example, one of my former patients had stopped playing golf because his body weight increased by ⬎100 kg. During our discussion of the results of his HRQOL assessment, however, it became evident to him that he had also abandoned many activities that he had previously enjoyed (e.g., mowing his lawn and taking his grandchild on day trips). Thus, as a result of the HRQOL assessment we were able to identify significant areas of impairment that prompted him to focus more acutely on his weight-control efforts so that he could “reclaim” his former life. Thus, HRQOL assessments can help clinicians identify important domains of functioning, set goals, discuss treatment options, and tailor a given treatment approach to the particular desires and needs of the individual. Despite the evidence from the study by Kolotkin et al. (4) and others suggesting that 1) individuals with obesity report decreases in HRQOL, 2) HRQOL varies in predictable ways (i.e., as a function of whether or not treatment is sought and the type of treatment sought), and 3) weight loss improves HRQOL (3,5,6), it is important to note that there is no consensus on what constitutes HRQOL, its domains, or how it is best measured. As it stands now, most generic and disease-specific HRQOL measures (including the IWQOLLite) focus on how patients are functioning, including their ability to perform the usual roles in their lives. In essence, these instruments simply measure self-reported health status and are used essentially as proxies for direct assessments of functional performance. Although the conceptualization of HRQOL as self-reported functional capacity has gained ascendancy in recent years, some have argued (7) that unless investigators tap into individual patient values, they are measuring only perceived health status, not HRQOL. In other words, an

HRQOL score as typically derived does not reflect the values and meanings an individual places on his or her ability to perform a given function. The incorporation of individual values and preferences into HRQOL assessments will likely require researchers to supplement traditional questionnaire-based methodologies with other approaches (e.g., cognitive interviewing) that gather information on both the personal meanings associated with a given level of functioning and on the cognitive processes involved when one makes HRQOL judgments (8). Expanding both our conceptualization and measurement of HRQOL may not only increase our understanding of how obesity affects quality of life, but may also provide us with new ways to intervene to improve the lives of our patients. Nonetheless, within the current approaches to measuring HRQOL, the results of the study by Kolotkin et al. (4) confirm that the effects of obesity go far beyond its influence on physiological health parameters; obesity hampers an individual’s capacity to live a full and satisfying life across a variety of important domains. References 1. Fontaine KR, Bartlett SJ. Estimating health-related quality of life in obese individuals. Dis Manage Health Outcomes. 1998;3:61–70. 2. Fine JT, Colditz GA, Coakley EH, et al. A prospective study of weight change and health-related quality of life in women JAMA. 1999;282:2136 – 42. 3. Fontaine KR, Barofsky I. Obesity and health-related quality of life. Obes Revs. 2001;2:173–182. 4. Kolotkin RL, Crosby RD, Rhys Williams G. Health-related quality of life varies among obese subgroups. Obes Res. 2002;10:748 –56. 5. Fontaine KR, Barofsky I, Andersen RE, et al. Impact of weight loss on pain and health-related quality of life. Qual of Life Res. 1999;8:275–7. 6. Samsa GP, Kolotkin RL, Williams GR, Nguyen MH, Mendel CM. Effect of weight loss on health-related quality of life: an analysis of combined data from four randomized trials of sibutramine versus placebo. Am J Manag Care. 2001;7: 875– 83. 7. Gill TM, Feinstein AR. A critical appraisal of quality-of-life measurements. JAMA. 1994;272:619 –26. 8. Lohr KN. Health Outcomes Methodology symposium: Summary and recommendations. Med Care. 2000;38(Suppl 2): 194 –208.

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