Secondary Logo

Journal Logo

Effects of obesity and some sociodemographic determinants on health-related quality of life in school-aged children in Greater Cairo

Elserougy, Safaaa; Salama, Somaiab; Salama, Imanb; Shaaban, Fatmac; Sami, Samiac

doi: 10.1097/01.MJX.0000414712.54546.57
ORIGINAL ARTICLES
Free

Objective To study the effects of childhood obesity on health-related quality of life (HRQOL) among school children.

Participants and methods The study included three comparable groups: healthy weight, overweight, and obese school children in Greater Cairo (n=410). They were of both sexes. Data on child-reported sociodemographic and the HRQOL questionnaire, weight, and height were collected.

Results The overweight and obese children had significantly poorer total and domain HRQOL scores compared with the healthy weight group (P<0.05), except for low self-esteem and public distress. Only the psychological distress and weight-related symptom measure domains showed significantly poorer scores in obese children compared with overweight children, who also had poorer scores compared with the healthy weight group. Across all sociodemographic strata (age, sex, social class, or mother’s education), the total HRQOL score was poorer in the obese and overweight group compared with the healthy weight group. Low social class, obesity, and younger age (≤12 years) were the significant predictors of a poor total HRQOL score.

Conclusion The problem of obesity and negative sociodemographic determinants in children should be dealt with comprehensively as early as possible to promote their HRQOL.

Departments of aEnvironmental and Occupational Medicine

bCommunity Medicine

cChild Health, National Research Center, Cairo, Egypt

Correspondence to Somaia Salama, Department of Community Medicine, National Research Centre, El-Bohouth Street, Dokki, 2311 Cairo, Egypt Tel: +002 023 333 5965; fax: +002 023 337 0931; e-mail: salamasomia@yahoo.com

Received November 20, 2011

Accepted January 10, 2012

Back to Top | Article Outline

Introduction

The increasing rates of childhood obesity have been identified as a major public health problem that threatens children’s health considerably 1. The national Egyptian levels of overweight and obesity have been determined to be 18% in boys and 22.9% in girls 2. El Derwi et al.3 reported that 34.2% of school children were overweight and obese in the Fayoum governorate in Egypt and significantly more prevalent among girls (39%) than boys (30.5%). The increasing prevalence and severity of obesity might be attributed to the complex interactions between genes, dietary intake, physical activity, and the environment 4. Childhood overweight and obesity in children is now so endemic that many countries are reporting a prevalence of 25% or higher 5.

Health-related quality of life (HRQOL) is defined as a multidimensional concept, which includes an individual’s subjective evaluation of his/her physical, emotional, and social well-being 6. It has become a well-established patient-reported outcome for clinical trials in the past decade. It refers to the subset of quality of life (QOL) directly related to an individual’s health 7. In recent years, there has been extensive interest in the HRQOL of obese individuals 8,9.

Overweight and obesity are associated with many severe medical consequences even at a young age 10,11. As childhood overweight and obesity lead to a significant reduction in health-related functioning, this could have consequences on the population beyond the known complications associated with concurrent and future cardiovascular, endocrine, and psychosocial morbidity 12. Although childhood obesity can lead to such problems, efforts to examine HRQOL in overweight and obese youth have increased 13. Moreover, HRQOL is of particular interest in overweight and obese youth as, at younger ages, psychosocial impairments are more prevalent than somatic comorbidities 14, and the most common short-term consequences of childhood obesity are psychosocial in nature 15,16.

Social class is a traditional sociological concept. The concept of social class has been used to understand not only inequality in economic well-being but also several factors such as differences in lifestyles and social conflicts 17. Kawachi et al.18 found that both low income and increased income have been found to be associated with a decrease in physical activity.

Schwimmer et al.19 reported that ‘severely obese children and adolescents have lower HRQOL than healthy children and adolescents and have similar HRQOL as those diagnosed as having cancer’. However, if this association remains for overweight and obese children across the population, then a substantial proportion of children and adolescents could be experiencing poor HRQOL because of their weight 20. The last decade has witnessed a marked increase in the development and utilization of pediatric HRQOL measures in an effort to improve patient health and well-being and to determine the value of healthcare services 21. The construct of HRQOL enables health agencies to legitimately address broader areas of public health policy around a common theme in collaboration with a wider circle of health partners, including social service agencies, community planners, and business groups 22. The present study aimed to study the effects of overweight, obesity, or certain sociodemographic determinants on HRQOL in samples of primary to secondary school children in Greater Cairo.

Back to Top | Article Outline

Participants and methods

Participants

This study was a cross-sectional case–control study carried out over a period of 6 months from January 2010 to June 2010. The ethical and formal consent of the educational authorities as well as verbal consent from all the participants in the study were obtained. The participants were primary to secondary school children recruited from six governmental schools in Greater Cairo (three schools from the Cairo governorate and three schools from the Giza governorate). The total number of children who participated in this study was 410. Both sexes were included and their ages ranged between seven and 16 years. All the children were apparently healthy with no history of chronic or acute illnesses.

Back to Top | Article Outline

Methods

Data were collected using a questionnaire of child-reported sociodemographic and HRQOL data, in addition to anthropometric measurements. The questionnaire was administered to school children during a face-to-face interview to ensure validity of the collected data and to avoid bias or incomplete data. Pretesting of the questionnaire in a pilot study was carried out before the study to check the reproducibility of the answers to the questions in a timely manner, and to avoid intervariation and intravariation between the interviewers.

Back to Top | Article Outline

The sociodemographic data

Sociodemographic data in terms of age, sex, residence, father’s occupation, and mother’s education were collected. Because the children in the present study did not have knowledge of their parents’ income, assets, and property ownership, only the father’s occupation was taken into consideration to indicate the social class, given that lifestyle and economic well-being are mostly expected to be same in each class. Barker 23 reported that children and wives’ social class should usually be taken from that of father or husband; but, the frequency of some common childhood diseases may be more closely related to the educational level of the mother rather than the father. Therefore, only the father’s occupation and the mother’s education were considered in the present study. The social class of the children was classified according to the EGP class schema of their fathers’ occupation into high class (higher grade and lower grade professionals), middle class (employers, self-employees, agricultural proprietors, routine nonmanual workers including clerical employees in administration and commerce, and routine nonmanual employees in sales and services), and lower class (skilled manual workers, unskilled manual workers, and agricultural workers) 24,25. Mother’s education was classified into three strata: illiterate, primary to secondary school educated, and university educated.

Back to Top | Article Outline

The health-related quality-of-life questionnaire

The HRQOL questionnaire consisted of five domains of HRQOL (54 dichotomous questions) for children. The replies were coded as zero for a good response and one for a poor response. Consequently, higher scores indicated poorer HRQOL. The domains of physical dysfunction, low self-esteem, and public distress were derived and modified from the 31-item version of the IWQOL-Lite 8. The domains of illness symptoms were derived and modified from the Weight-Related Symptom Measure (WRSM) 26. The psychological distress domain was derived from the Modified Obesity and Quality-of-Life (O-QOL) 17-Item questionnaire 26. The questionnaire was translated into Arabic by the authors. Then, without reading the original English version, the Arabic translation of the questionnaire was retranslated into English by an English reader. The original questionnaire and the English retranslation of the questionnaire were compared to refine the Arabic translation. A pilot testing of the questionnaire was carried out. The refined Arabic and the original English versions were answered by 21 bilingual children to determine internal consistency. The refined Arabic version was again administered on the same 21 children after 1 week to assess test–retest reliability. The questionnaire included the following domains:

  • Physical dysfunction domain: describes both functional limitations: (a) picking up objects, tying shoes, getting up from chairs, using stairs, dressing, mobility, crossing legs, feel short of breath, painful stiff joints and/or (b) limitations attending school, difficulty in performing household tasks, limitations in doing strenuous acts, and difficulty with personal care and hygiene.
  • Self-esteem domain: unsure of self, do not like myself, afraid of rejection, avoid looking in mirrors, embarrassed in public.
  • Public distress domain: experience ridicule, fitting in public seats, worry about finding chairs, experience discrimination.
  • WRSM domain: tiredness, sleep problems, sensitivity to cold, increased thirst, increased irritability, back pain, frequent urination, pain in the joints, water retention, foot problems, sensitivity to heat, snoring, increased sweating, appetite, leakage of urine, increased skin irritation.
  • Psychological distress domain (Modified O-QOL 17-Item questionnaire): (1) Because of my weight, I try to wear clothes that hide my shape. (2) I feel frustrated that I have less energy because of my weight. (3) I feel guilty when I eat because of my weight. (4) I am bothered by what other people say about my weight. (5) Because of my weight, I try to avoid having my photograph taken. (6) Because of my weight, I have to pay close attention to personal hygiene. (7) My weight prevents me from doing what I want to do. (8) I worry about the physical stress that my weight puts on my body. (9) I feel frustrated that I am not able to eat what others do because of my weight. (10) I feel depressed because of my weight. (11) I feel ugly because of my weight. (12) I worry about the future because of my weight. (13) I envy people who are thin. (14) I feel that people stare at me because of my weight. (15) I have difficulty accepting my body because of my weight. (16) I am afraid that I will gain back any weight that I lose. (17) I get discouraged when I try to lose weight.

Anthropometric measurements of height and weight were carried out. Height was measured using Holtain portable anthropometry to the nearest 0.5 cm and weight was measured with precision to the nearest 0.1 kg using a Seca scale balance with the child dressed in minimal clothes and without shoes. The BMI was calculated (kg/m2). When assessed in particular age and sex groups, BMI is a statistically valid measure of overweight among children and adolescents 27. Age-specific and sex-specific BMI percentiles of the participant children were derived using growth charts for healthy Egyptian children 28. The study included three groups (healthy weight, overweight, and obese) with age-specific and sex-specific BMI percentiles of at least 85th and at least 95th percentiles for the overweight and the obese groups, respectively 29,30. The number of children in the three groups was 240 (58.5%), 96 (23.4%), and 74 (18.1%), respectively.

Back to Top | Article Outline

Data entry and statistical analysis

Data entry and statistical analysis were carried out using SPSS software package (SPSS v14.0; Chicago, Illinois, USA). The internal consistency of the Arabic and English versions was assessed using Cronbach’s α coefficients. The test–retest reliability of the Arabic version was assessed using single-measure intraclass correlation coefficients (ICC). For all domains, the internal consistency was moderate to high (Cronbach’s α>0.6) and test–retest reliability was good to very good (ICC>0.6) 31. Scores of the domains of physical dysfunction, psychological distress, low self-esteem, public distress, and illness symptoms were derived and the total scores were computed. The level of significance was set at P less than 0.05 in the present study. Differences in the demographic variables were determined using χ2-tests for categorical variables and analysis of variance for continuous variables to test for significant overall mean differences by bodyweight groups. Statistical analysis between groups was performed by the ANOVA test; with the least significant difference formula for post hoc multiple comparisons. Least significant difference tests were used to calculate the marginal means for pair-wise comparisons between bodyweight groups to determine which (if any) groups led to any significant overall differences found. Kruskal–Wallis and Mann–Whitney tests were used as alternative nonparametric tests for continuous variables in the case of a nonnormal distribution. Bivariate Pearson correlations and linear regression models of HRQOL were performed to determine the relationship between obesity and HRQOL.

Back to Top | Article Outline

Results

There were no statistically significant differences between healthy weight, overweight, and obese groups in terms of the mean age, the sex distribution, social classes, and mothers’ education (Table 1). The overweight and obese groups showed statistically significant poorer (higher) total and domain HRQOL scores (P<0.05) compared with the healthy weight group, except for public distress in both groups and self-esteem in the obese group. Only the psychological distress and WRSM domains showed significantly poorer (higher) scores, with significant intergroup differences (P<0.05) (Table 2).

Table 1

Table 1

Table 2

Table 2

In young children (≤12 years) and adolescents, the overweight and obese groups showed significantly poorer (higher) total HRQOL scores compared with the healthy weight group. Furthermore, the score was poorer (higher) in the younger age group in the healthy weight group and, in general, in all the children. In terms of sex, total HRQOL did not show differences between males and females. However, only the females in the overweight group had significantly poorer total HRQOL scores compared with the healthy weight group. As for all social classes, the overweight and obese groups had significantly poorer (higher) total HRQOL scores compared with the healthy weight group, except for overweight children from a high social class. Furthermore, the score became significantly poorer (higher) with a decrease in social class in all children. In the healthy weight group, children from a low social class had a poorer total HRQOL score compared with those from high and middle social classes (P<0.001 and P<0.05, respectively). However, in the overweight group, only children from a low social class had poorer scores compared with those from a high social class (P<0.001), with no statistically significant differences across the different social classes in the obese group. In terms of mothers’ education, the overweight and obese groups had significantly poorer (higher) total HRQOL scores compared with the healthy weight group. However, the overweight group, which included children with illiterate mothers, was not statistically different from the corresponding healthy weight group. In terms of the differences in the HRQOL score for mothers’ education, the overweight and obese groups did not show any significant interstrata differences. However, all participantsand the children in the healthy weight group had significantly HRQOL poorer (higher) scores in the illiterate and primary to secondary strata compared with university stratum (Table 3).

Table 3

Table 3

With respect to the relation of sex to the scores of the five domains of HRQOL, the males in the healthy weight group showed significantly poorer (higher) scores in the public distress domain than females of the same group (P=0.01) (Fig. 1).

Fig. 1

Fig. 1

There were significant correlations between age in the overweight group and all HRQOL scores, except low self-esteem and public distress. This indicated an improvement in these scores with age. However, in the overweight and obese groups, BMI percentile only showed a significant negative correlation with public distress and WRSM in the overweight and physical dysfunction in the obese group. This indicated an improvement in the former two scores and worsening with BMI percentile (Table 4). Linear regression models for the total and domain HRQOL were constructed for all the children. Low social class, high BMI percentile, and young age were significant predictors of poor total HRQOL. Low social class also appeared to be a significant predictor of all domains of HRQOL, except low self-esteem. High BMI percentile was a significant predictor of psychological distress, public distress, and WRSM, whereas younger age was only a significant predictor of psychological distress (Table 5).

Table 4

Table 4

Table 5

Table 5

Back to Top | Article Outline

Discussion

Many studies have reported that obese children and adolescents have poorer HRQOL not only in the total domain score but also in all domains (physical, emotional, social, and school life) compared with their normal-weight peers 32–35, which is in agreement with the results of the present study, except for public distress. Kolotkin et al.36 found statistically significant differences between the overweight and the obese groups for all domains. Similarly, Schwimmer et al.19 reported that children’s HRQOL was markedly more decreased in obese than overweight children. This was also found in the present study, in which overweight and obese children seemed to have the same HRQOL, except psychological distress and WRSM, but poorer than those of healthy weight children. Kolotkin et al.36 reported a significant difference between the healthy weight and overweight adolescents, especially in the domain of body esteem, with the overweight children reporting lower QOL scores. Moreover, Wille et al.14 found that overweight children showed impairments in their perceived health, social, and emotional well-being, but other dimensions of HRQOL such as physical well-being, psychological well-being, self-esteem, family and school life as well as overall HRQOL were not significantly impaired.

The domain of physical dysfunction describes the subjective perception of how weight affects mobility and comfort in daily life. Obesity has negative effects on functional status including work absenteeism, productivity, bodily pain, and depression 37. Kaukua 38 found that overweight and obesity affected physical functioning more strongly than mental functioning. In contrast, Sato et al.39 reported that the overall QOL scores did not differ significantly among their three studied groups (underweight, normal weight, and overweight). The domain of body esteem assesses the impact of weight on body self-perceptions and appearance.

In contrast to the present results of poorer total HRQOL in children than in adolescents, Wille et al.13 reported that because of the marked decrease in HRQOL in the general population during adolescence, compared with age-specific norms, adolescents had less impairments than children. However, overweight and obese adolescents (especially females) reported the poorest absolute HRQOL scores.

The effect of sex in the present study seemed to be negligible on total and almost all the domains of HRQOL. This is in agreement with the study of Riazi et al.40, whose results were found to be similar for boys and girls, and suggests that the impact of obesity is not necessarily sex specific. In contrast to our results, Kunkel et al.34 reported that the QOL of female adolescents compared with that of males was lower among both the excess weight group and the normal weight group. These results are expected as many studies have shown that female adolescents have greater concern with their body image 41,42. Other authors have found that overweight and obese adolescent females reported lower quality-of-life scores than males 13,34. It is widely accepted that females, in general, report poorer body esteem 43 and poorer emotional functioning 44 compared with males. Modi et al.45 found that males reported higher scores on the emotional domain compared with females. Normal-weight boys reported higher physical functioning scores than their obese peers. Normal-weight girls reported higher physical functioning and average HRQOL scores than obese girls. Normal-weight and overweight boys reported higher average HRQOL scores than girls 46. Another study showed that obese female adolescents were significantly more likely to report lower QOL than those with normal weight in all domains, except the emotional domain. For male adolescents, this difference remained significant only for the total domain score 34. Tsiros et al.47 reported an inverse relationship between BMI and pediatric HRQOL with impairments in physical and social functioning.

In the present study, it was found that mother’s education played no apparent role in HRQOL in each group. In contrast, Williams et al.20 reported that low maternal education was associated with a significant decrease in the pediatric QOL in the higher weight category. HRQOL is rather affected by the father’s occupation/social class than by the mother’s education. Lower socioeconomic status is associated with a reduction in quality-adjusted life years, mediated partly through behavioral risk factors such as obesity, smoking, a sedentary lifestyle, and alcohol 48. In agreement with the results of the present study, Minet Kinge and Morris 49 reported that the negative impact of obesity was greater on HRQOL in individuals from lower socioeconomic groups. Moreover, they found that overweight and obese individuals in lower socioeconomic groups had lower HRQL than those of normal-weight individuals in the same socioeconomic group, and had lower HRQL than those in higher socioeconomic groups of the same weight. The disparities in the risk of overweight and obese status among those with limited economic resources has remained and even increased; indigent adolescent males, for example, are more likely to remain overweight, and indigent adolescent females are more likely to become overweight, than their peers with greater economic resources 50. Factors in the environment may contribute to the relation between lower socioeconomic status and obesity; these factors may include walkability of the neighborhood 51.

Back to Top | Article Outline

Conclusion and recommendation

This study focused on the evaluation of determinants of poor HRQOL in children. Obesity, overweight, and lower social class predispose to poor HRQOL in children. This problem should be dealt with as early as possible comprehensively: obesity and HRQOL and the underlying sociodemographic determinants. For health providers, total and domain HRQOL can yield a better understanding of life and health aspects that are most affected by overweight and obesity in children. HRQOL can be used by physicians and teachers to assess the effectiveness of obesity management and lifestyle health education.

Figure

Figure

Back to Top | Article Outline

Acknowledgements

Conflicts of interest

There are no conflicts of interest.

Back to Top | Article Outline

References

1. Schwartz MB, Puhl R. Childhood obesity: a societal problem to solve. Obes Rev. 2003;4:57–71
2. Shaheen FM, Hathout M, Tawfik AA National survey of obesity in Egypt. 2004 Cairo, Egypt National Nutrition Institute
3. El Derwi D, El Sherbiny N, Atta AH. Exploring Fayoum (Upper Egypt) preparatory school students’ and teachers’ attitude towards obesity as health risk. J Public Health Epidemiol. 2011;3:401–406
4. Biro FM, Wien M. Childhood obesity and adult morbidities. Am J Clin Nutr. 2010;91:1499S–1505S
5. Lobstein T, Baur L, Uauy R. Obesity in children and young people: a crisis in public health. Obes Rev Suppl. 2004;5:4–104
6. Schipper H, Clinch JL, Olweny LMSpilker B. Quality of life studies: definitions and conceptual issues. Quality of life and pharmacoeconomics in clinical trials. 19952nd ed. Philadelphia, USA Lippincott Williams & Wilkins:11–24
7. Sherman EMS, Slick DJ, Connolly MB, Steinbok P, Camfield C, Eyrl KL, et al. Validity of three measures of health-related quality of life in children with intractable epilepsy. Epilepsia. 2002;43:1230–1238
8. Kolotkin RL, Meter K, Williams GR. Quality of life and obesity. Obes Rev. 2001;2:219–229
9. Fontaine KR, Barofsky I. Obesity and health-related quality of life. Obes Rev. 2001;2:173–182
10. Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. J Am Med Assoc. 2003;289:187–193
11. Malecka Tendera E, Mazur A. Childhood obesity: a pandemic of the twenty-first century. Int J Obes. 2006;30(Suppl 2):S1–S3
12. Wake M, Salmon L, Waters E, Wright M, Hesketh K. Parent-reported health status of overweight and obese Australian primary school children: a cross-sectional population survey. Int J Obes. 2002;26:717–724
13. Wille N, Bullinger M, Holl R, Hoffmeister U, Mann R, Goldapp C, et al. Health-related quality of life in overweight and obese youths: results of a multicenter study. Health Qual Life Outcomes. 2010;8:36
14. Wille N, Erhart M, Petersen C, Ravens Sieberer U. The impact of overweight and obesity on health-related quality of life in childhood – results from an intervention study. BMC Public Health. 2008;8:421
15. Reilly JJ, Methven E, McDowell ZC, Hacking B, Alexander D, Stewart L, et al. Health consequences of obesity. Arch Dis Child. 2003;88:748–752
16. Warschburger P. The unhappy obese child. Int J Obes. 2005;29(Suppl 2):S127–S129
17. Wright EO Approaches to class analysis. 2005 Cambridge, UK Cambridge University Press
18. Kawachi I, Kennedy BP, Lochner K, Prothrow Stith D. Social capital, income inequality and mortality. Am J Public Health. 1997;87:1491–1498
19. Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. J Am Med Assoc. 2003;289:1813–1819
20. Williams J, Wake M, Hesketh K, Maher E, Waters E. Health-related quality of life of overweight and obese children. J Am Med Assoc. 2005;293:70–76
21. Varni JW, Burwinkle TM, Lane MM. Health-related quality of life measurement in pediatric clinical practice: an appraisal and precept for future research and application. Health Qual Life Outcomes. 2005;34:1–9
22. Kindig DA, Booske BC, Remington PL. Mobilizing Action Toward Community Health (MATCH): metrics, incentives and partnerships for population health. Prev Chronic Dis. 2010;7:A68
23. Barker DJ Practical epidemiology. 19833rd ed. Edinburgh Churchill Livingstone
24. Goldthorpe JH On sociology. 20072nd ed. Stanford Stanford University Press
25. Torche F Sociological and economic approaches to the intergenerational transmission of inequality in Latin America (HD-09-2009). 2009 New York RBLAC-UNDP
26. Melanson KJ, McInnis KJ, Rippe JM, Blackburn G, Wilson PF, Cheitlin MD. Obesity and cardiovascular disease risk: research update. Cardiol Rev. 2001;9:202–207
27. Himes JH, Dietz WH, Bray G, Guo S, Roche AF, Story M, et al. Guidelines for overweight in adolescent preventive services: recommendations from an expert committee. Am J Clin Nutr. 1994;59:307–316
28. Ghalli I, Salah N, Hussein F, Erfan M, El Ruby M, Mazen I, et al. Egyptian growth curves for infants, children and adolescents. Crecere nel mondo. In: Satorio A, Buckler JMH, Marazzi N. Italy: Ferring Publisher; 2008
29. Barlow SE. Expert committee recommendations regarding the prevention, assessment and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(Suppl 4):S164–S192
30. About BMI for children and teens. 2011; Available at: http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens [Accessed 20 October 2011]
31. De Bourdeaudhuij I, Klepp KI, Due P, Perez Rodrigo C, De Almeida MDV, Wind M, et al. Reliability and validity of a questionnaire to measure personal, social and environmental correlates of fruit and vegetable intake in 10–11-year-old children in five European countries. Public Health Nutr. 2005;8:189–200
32. Pinhas Hamiel O, Singer S, Pilpel N, Fradkin A, Modan D, Reichman B. Health-related quality of life among children and adolescents: associations with obesity. Int J Obes. 2006;30:267–272
33. Zeller MH, Modi AC. Predictors of health-related quality of life in obese youth. Obesity. 2006;14:122–130
34. Kunkel N, de Oliveira WF, Peres MA. Overweight and health-related quality of life in adolescents of Florianópolis, Southern Brazil. Rev Saude Publica. 2009;43:226–235
35. Østbye T, Malhotra R, Wong HB, Tan SB, Saw SM. The effect of body mass on health-related quality of life among Singaporean adolescents: results from the SCORM study. Quality Life Res. 2010;19:167–176
36. Kolotkin RL, Zeller M, Modi AC, Samsa GP, Quinlan NP, Yanovski JA, et al. Assessing weight-related quality of life in adolescents. Obesity. 2006;14:448–457
37. Patrick DL, Bushnell DM, Rothman M. Performance of two self-report measures for evaluating obesity and weight loss. Obes Res. 2004;12:48–57
38. Kaukua J Health-related quality of life in clinical weight loss studies. 2004 Helsinki, Finland Medical Faculty of the University of Helsinki
39. Sato H, Nakamura N, Sasaki N. Effects of bodyweight on health-related quality of life in school-aged children and adolescents. Pediatr Int. 2008;50:552–556
40. Riazi A, Shakoor S, Dundas I, Eiser C, McKenzie SA. Health-related quality of life in a clinical sample of obese children and adolescents. Health Qual Life Outcomes. 2010;8:134
41. Rand CSW, Resnick JL. The ‘good enough’ body size as judged by people of varying age and weight. Obes Res. 2000;8:309–316
42. Conti MA, Frutuoso MFP, Gambardella AMD. Obesity and body dissatisfaction amongst adolescents. Rev Nutr. 2005;18:491–497
43. Feingold A, Mazzella R. Gender differences in body image are increasing. Psychol Sci. 1998;9:190–195
44. Galambos NL, Leadbeater BJ, Barker ET. Gender differences in and risk factors for depression in adolescence: a 4-year longitudinal study. Int J Behav Dev. 2004;28:16–25
45. Modi AC, Loux TJ, Bell SK, Harmon CM, Inge TH, Zeller MH. Weight-specific health-related quality of life in adolescents with extreme obesity. Obesity. 2008;16:2266–2271
46. Fazah A, Jacob C, Moussa E, El Hage R, Youssef H, Delamarche P. Activity, inactivity and quality of life among Lebanese adolescents. Pediatr Int. 2010;52:573–578
47. Tsiros MD, Olds T, Buckley JD, Grimshaw P, Brennan L, Walkley J, et al. Health-related quality of life in obese children and adolescents. Int J Obes. 2009;33:387–400
48. Muennig P, Lubetkin E, Jia H, Franks P. Gender and the burden of disease attributable to obesity. Am J Public Health. 2006;96:1662–1668
49. Minet Kinge J, Morris S. Socioeconomic variation in the impact of obesity on health-related quality of life. Soc Sci Med. 2010;71:1864–1871
50. Sherwood NE, Wall M, Neumark Sztainer D, Story M. Effect of socioeconomic status on weight change patterns in adolescents. Prev Chronic Dis. 2009;6:A19
51. Sallis JF, Saelens BE, Frank LD, Conway TL, Slymen DJ, Cain KL, et al. Neighborhood built environment and income: examining multiple health outcomes. Soc Sci Med. 2009;68:1285–1293
© 2012 Medical Research Journal