INGESTIVE BEHAVIOR AND OBESITY
Obesity and Quality of Life Robert F. Kushner, MD and Gary D. Foster, PhD From the Department of Medicine, Northwestern University, Chicago, Illinois; and the Department of Psychiatry, University of Pennsylvania, USA The focus of this review is the impact of obesity and weight loss on quality of life. A focus on quality of life broadens the scope of treatment efficacy beyond weight loss and provides a patient-centered perspective. The concept of quality of life is defined, and both general and obesity-specific measures are reviewed. It is clear that obesity confers negative consequences on both the physical and psychosocial aspects of quality of life, especially among the severely obese. The effects of weight loss appear to be favorable, although few studies have examined non-surgical interventions. Future studies would be enhanced by assessing a variety of approaches to weight loss by using both general and obesity-specific measures of quality of life and conducting follow-up studies to assess the effects of weight regain on quality of life. Nutrition 2000;16:947–952. ©Elsevier Science Inc. 2000 Key words: obesity, quality of life
INTRODUCTION The other articles in this special issue of Nutrition provide a thorough review of the literature on key topics, including genetic and metabolic control systems, that govern regulation of body weight, the biological systems that control hunger and satiety, the use of current and future pharmacologic agents, and obesityrelated morbidity and mortality. In contrast, this review provides a unique perspective on obesity from the patient’s point of view. By using health-related quality of life (HRQL) instruments, we are able to gain insight to the patients’ subjective experience of being overweight: to capture their feelings, values, abilities, and expectations. We can use these instruments to assess their perceptions of what it is like to be obese and the changes that result from various weight-reduction interventions. Over the past decade, evaluation of HRQL has become an essential clinical and research outcome measurement. It is important to remember that the primary therapeutic goal of any obesity intervention is to improve the patient’s outlook and not simply promote weight loss.
MEASUREMENT OF HEALTH STATUS AND QUALITY OF LIFE When patients are asked why they are seeking treatment for obesity, their responses are generally related to disappointment with their appearance or difficulty with daily physical functioning due to shortness of breath, pain of the weight-bearing joints, low energy levels, and/or reduced mobility. Other patients may present with psychological concerns such as low self-esteem and disturbance of body image. Occasionally, patients will relay other health-related concerns, such as newly diagnosed illnesses or fear of acquiring such diseases. In summary, a self-perceived reduction in quality of life is one of the major personal consequences of obesity and constitutes one of the main reasons for seeking medical attention.1 Furthermore, daily functioning and quality of life can be severely diminished without having an impact on morbidity or other metabolic and physiologic markers.2 Although these
Correspondence to: Robert Kushner, MD, Professor of Medicine, Northwestern University, 240 East Ontario Street, Suite 400, Chicago, IL 60611, USA. E-mail:
[email protected] Date accepted: May 19, 2000. Nutrition 16:947–952, 2000 ©Elsevier Science Inc., 2000. Printed in the United States. All rights reserved.
quality-of-life issues may be recorded in the patient’s medical chart, they are not routinely measured and quantified. The development of health-assessment instruments over the past 20 y have allowed researchers and clinicians to measure these concerns of functioning and well-being. By capturing and analyzing these subjective data, we are able to advance understanding and appreciate the meaningfulness of obesity from the patient’s point of view. The term quality of life encompasses standard of living, quality of housing and neighborhood, job satisfaction, family relationships, health, and other factors.3 Quality of life is the individual’s overall satisfaction with his life, based on his own values, goals, abilities, and needs.4 Because clinicians and health-care researchers are most interested in those aspects of life that are more closely related to health status, e.g., vitality, physical and mental functioning, measurement of these HRQL factors has been called healthrelated quality of life.5 In general, HRQL instruments are categorized as either generic or disease specific. Generic measurements are designed for administration to people with any underlying health problems and cover all relevant areas of HRQL. These instruments address issues that essentially all people would consider important to their health, such as mobility, self-care, and physical, emotional, and social function.6 The major advantages of using these measurements are their simplicity and ability to compare the relative HRQL of one disease or condition to another. Well-established and validated examples of generic HRQL measurements are the Medical Outcomes Study. The Short-Form Health Survey (SF-36)7 and the Sickness Impact Profile.8 The SF-36 contains 36 questions measuring eight domains of functioning: physical functioning, role limitations due to physical health problems, social functioning, bodily pain, general mental health, role limitations due to emotional problems, vitality, and general health perceptions. In contrast to generic measurements that may be poorly adapted to a particular patient population, disease-specific instruments are designed to capture information that is relevant to a specific illness. The major advantage of using a well-structured disease-specific devise is the ability to assess and record quality-of-life issues that are most meaningful to a particular population. For example, inquiring about daytime sleepiness, preoccupation with food, or hatred of one’s body may be pertinent questions for an obesityoutcomes trial but not particularly relevant to other disease conditions. Several obesity HRQL measurements have been developed and are reviewed. The most important decision for clinicians and researchers to make is to choose the best instrument(s) for 0899-9007/00/$20.00 PII S0899-9007(00)00404-4
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Nutrition Volume 16, Number 10, 2000 TABLE I. OBESITY–SPECIFIC HEALTH-RELATED QUALITY OF LIFE INSTRUMENTS
Reference
HRQL
Items
Comments
Impact of weight on quality of life Health-related quality of life, health-state preference
74
Le Pen et al.1
Obese-specific quality of life
11
Mannucci et al.4
Obesity-related well-being
18
Butler et al.12
Obesity adjustment survey— short form
20
Items represent eight scales: health, social/interpersonal, work, mobility, self-esteem, sexual life, activities of daily living, comfort with food Two-thirds of questions consist of previously existing, validated measures; one-third is obesity specific; the health-state preference is 15-min interview, and there are four levels of functioning: physical attractiveness, social functioning, health distress, and emotions Items represent four independent dimensions: physical state, vitality and desire to do things, relations with other people, psychological state Items represent two subscales: psychological status and social adjustment, physical symptoms, and impairment Survey developed for morbidly obese patients undergoing bariatric surgery
Kolotkin et al.10 Mathias et al.11
55
HRQL, health-related quality of life
their particular patient population. In a recent review article, Gill and Feinstein9 critically appraised 159 different quality-of-life instruments from 75 published articles. They found that only 36% of investigators gave reasons for selecting the chosen instrument and only 17% of articles included instruments in which patients rated their own global quality of life, a chief indicator of overall health. Important measurement properties to consider include validity (the instrument measures what it is intended), responsiveness (ability to detect change), and reliability (ratio of variability between patients to the total variability).6
OBESITY HRQL MEASUREMENTS At the time of this writing, we were able to identify five obesity HRQL instruments published in the medical literature (Table I). In general, the process used to construct the instruments was quite similar: obese patients and/or health professionals who treat this population were asked to generate questions (items) that represent relevant complaints and concerns. For most, the initial list of items was then modified and evaluated for test–retest reliability. Items were then categorized under specific domains or dimensions for interpretation. Because each investigator used a different population to construct the instrument, e.g., mild versus morbidly obese, surgical versus non-surgical, specific questions differ and may be more relevant for one group than for another. Because these devises have not been widely used, they require further testing to assess the measurement properties mentioned above. Nonetheless, the obesity-specific HRQL outcomes from these five articles and other studies that used generic HRQL devises have provided significant and meaningful information on quality-of-life issues in obesity.
IMPACT OF OBESITY ON GENERAL HEALTH The impact of obesity on overall daily functioning and quality of life is best measured by general health perceptions using several HRQL domains, including general health, physical, social, and emotional functioning, and vitality. Individuals with obesity uniformly perceive their general health as poorer than do healthyweight individuals.1,10 –12 Moreover, a continuum has been observed between mildly, moderately, and severely (morbidly) obese individuals and worsening perceived health status. Fontaine et al.13 administered the SF-36 questionnaire to 312 consecutive participants seeking outpatient weight-loss treatment at a university
program. Compared with U.S. population norms, obese participants scored significantly worse in all eight domains of the HRQL devise. Furthermore, the morbidly obese subgroup scored significantly worse in six of the eight scales compared with the lessobese categories (Table II). In a larger population sample of 1241 men and women from the Netherlands, Seidell et al.14 found that increasing body mass index (BMI) was associated with more subjective health complaints but that age was an effect modifier in the association. Richards et al.15 used an interesting study design by comparing the functional status of 145 sibling pairs, one classified as severely obese (BMI ⱖ 35) and the other sibling as normal weight (BMI ⬍ 27). All SF-36 functional status and emotional well-being scores were significantly lower in severely obese participants than in normal-weight siblings. Furthermore, severely obese pairs perceived their general health to be poorer and more likely to get worse than did normal-weight siblings.
EFFECTS OF OBESITY ON PHYSICAL FUNCTIONING Obesity places several physiologic demands on multiple organ functions that are physically perceived by the individual, most TABLE II. COMPARISON OF ADJUSTED MEDICAL OUTCOMES STUDY OF THE SHORT-FORM HEALTH SURVEY SHOWS MEAN SCORES BETWEEN THE U.S. POPULATION AND MILDLY, MODERATELY TO SEVERELY, AND MORBIDLY OBESE INDIVIDUALS*
SF-36 scale Physical functioning Physical role Bodily pain General health Vitality Social functioning Emotional role Mental health
U.S. norms (n ⫽ 2474)
Mildly (n ⫽ 35)
Moderately (n ⫽ 163)
Morbidly (n ⫽ 80)
84.5 81.1 75.4 72.2 61 83.5 81.2 74.8
85.6 85 66.4 72 49.5 84.9 85.4 74.3
79.4 77.8 54.5 65.7 48.1 79.3 75.3 68.6
51.9† 46.3† 43.2† 54.3† 38† 67.9† 69.3 65.6
* Adapted from Fontaine et al.13 † P ⬍ 0.001 versus either of the less-obese individual categories. SF-36, Short-Form Health Survey
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TABLE III. UNADJUSTED PREVALENCE OF SUBJECTS WITH CHRONIC DISEASE, SYMPTOMS, AND “POOR” QUALITY OF LIFE BY CATEGORY OF BODY MASS INDEX* Men (n ⫽ 1885) Proportions of subjects (%) Shortness of breath walking upstairs Low back pain At least one risk factor “Poor” quality of life Bending, kneeling Walking one flight of stairs Moderate activity
Women (n ⫽ 2156)
⬍25 11.2 14.5 23.6
⬎30 34.3 20 66.9
⬍25 18.4 17.8 15.4
⬎30 46.4 24.7 45.4
20.9 5.3 10.8
45.5 11.9 20.4
20.7 5.4 18.4
48.3 21.5 36
* Adapted from Lean et al.18 All obese-prevalence values were significantly higher (P ⬍ 0.001) than in those with healthy weight.
notably the heart and vascular system (blood and oxygen exchange), respiratory system (oxygen and carbon dioxide exchange), musculoskeletal system (mobility and weight bearing), and skin (heat loss and hygiene). The effect of obesity on the skin is particularly noticeable by increased sweating, cutaneous infections, and swelling and/or discoloration of the lower extremities. Other symptoms such as heartburn (gastroesophageal reflux)16 and urinary incontinence17 appear to be due to increased intraabdominal pressure. The physical burden of obesity is measured in generic HRQL instruments under several domains, e.g., physical functioning, role limitations due to physical problems, and bodily pain, and directly addressed in the disease-specific HRQL questionnaires. In large part, the poorer overall quality of life perceived in obesity is due to worse physical functioning. Lean et al.18 assessed the health status of approximately 14 000 Dutch men and women recruited randomly from civil registries between 1993 and 1995. Participants were queried about their health status and daily functioning. Virtually all health outcomes considered by the investigators were significantly influenced by BMI. As noted in Table III, there was a significant worsening in respiratory systems, low back pain, and “poor” quality of life in physical functioning as BMI categories increased. The encumbrance on physical functioning also appeared to affect women more than men. A more specific insight into the burden of obesity is revealed by the disease-specific HRQL questionnaires that attempt to capture real-life elements that distinguish this population from normal-weight healthy patients. For example, Le Pen et al.1 found the following items to be uniquely discriminating on their HRQL: “I don’t move around very much,” “When I climb stairs, I have to rest to catch my breath after several steps,” “I walk as little as possible,” “I have trouble squatting and kneeling,” and “I have trouble getting on and off buses, trains, subways, etc.” Examples of questions from Mannucci et al.4 include: “Does sweating interfere with your daily activities?” and “Does your weight represent a physical obstacle for your sexual activity?” A gradient of worsening symptoms is seen as patients progress from mild to morbid obesity. The deterioration in physical function seen among the moderately or morbidly obese is also reflected on the SF-36 instrument in the bodily pain domain. When asked, “How much bodily pain have you had over the last 4 wk?” nearly 50% of patients reported moderate or more severe pain in a study by Barofsky et al. of 312 patients seeking weight-control treatment.19 Low back pain was identified as the most prevalent site. When bodily pain scores were compared with published data of several chronic conditions, the obese participants in the study reported significantly greater body
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pain than did those with depression, congestive heart failure, or human immunodeficiency virus. Only patients with migraine headaches had a higher score.13 In the study by Richards et al. comparing obese and normal-weight sibling pairs, the severely obese individuals reported bodily pain as more severe and limiting. An increased prevalence of low back pain and symptoms of intervertebral disk herniation was also seen among the Dutch study of 14 000 men and women.20 Forty-three to 48% of obese men and 48% to 56% of obese women complained of low back pain over the past year. Sleep-disordered breathing and daytime somnolence represent one of the most commonly unrecognized problems seen in the obese population. Symptoms of snoring, nighttime awakening, morning headaches, daytime drowsiness, and poor concentration should raise the suspicion of obstructive sleep apnea (OSA). Accordingly, this disease may cause a significant impairment in quality of life. Two recent studies have examined the psychosocial impact of OSA in obesity. Stoohs et al. examined 90 commercial long-haul truck drivers aged 20 to 64 y for sleep-disordered breathing and frequency of automotive accidents.21 Drivers completed a questionnaire on sleeping habits, daytime functioning and sleep tendency, alertness, and number of driving accidents over the past 5 y. A polysomnogram was also performed to measure the oxygen desaturation index. The researchers found that obese truck drivers with a BMI of 30 or more were significantly more sleepy than non-obese truck drivers, had a higher oxygen desaturation index, and had a two-fold higher accident rate than did non-obese truck drivers. In a second study by Grunstein et al., 3000 obese men and women enrolled in the Swedish Obesity Subjects Study were evaluated for OSA.22 Frequent sleepiness, irresistible sleep episodes, and arousals from sleep were reported more often in the 25% of men and 9% of women classified as having the sleepdisordered disease. Compared with non-OSA subjects, women and men with OSA had higher rates of divorce, impaired work performance, more sick leave, and worse self-rated general health. Women also reported more anxietylike symptoms and psychiatric consultations. These studies have shown that perceived quality of health of obese individuals worsens with increasing BMI. However, a confounding factor in the interpretation of these data is the associated increasing risk for co-morbid illnesses, such as diabetes, hypertension, and depression, that may account for the deteriorating selfreported health. Doll et al. recently clarified this association in their study of 8600 British individuals who completed the HRQL SF-36 instrument and a self-questionnaire on other health-related problems.23 Of the respondents, approximately one-third were overweight (BMI ⫽ 25–29.9) and an additional 11% were categorized as obese (BMI ⬎ 30). The risk of suffering from any longstanding illness was associated with increasing BMI, increasing from 35% of those who were overweight to 68% of those who were morbidly obese. Similar to other studies, there were statistically significant differences in SF-36 scores among the BMI categories, with worsening scores associated with increasing BMI. Physical well-being was observed to deteriorate with increasing number of illnesses and with the additional presence of obesity. Thus, both obesity and the number of longstanding illnesses were independently related to physical functioning. This study suggests that the quality of life for obese individuals worsens with increasing body weight and with the number of acquired co-morbid illnesses.
EFFECTS OF OBESITY ON PSYCHOLOGICAL FUNCTIONING Despite the serious physical consequences associated with obesity, an expert panel, composed predominantly of physicians, concluded: “Obesity creates an enormous psychological burden. In
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terms of suffering, this burden may be the greatest adverse effect of obesity.”24 Numerous population studies have shown few significant differences between obese and non-obese participants on standardized measures of psychopathology (for review, see Wadden and Stunkard25). Body-image dissatisfaction26 and bingeeating disorder27,28 are two conditions that are more common among the obese. Although few obese patients have clinically significant problems with body image,29 binge-eating disorder is associated with higher rates of psychopathology, in particular depression.28 Despite the lack of difference in population means, some obese people do suffer from clinically significant psychopathology that requires treatment. Research is needed to examine factors that may increase the risk for psychopathology among the heterogeneous obese population.30 A recent study has suggested that gender may modify the psychological risk of obesity.31 In a general population sample, excess weight among women was associated with an increased risk of major depression, suicidal thoughts, and suicide attempts. In contrast, excess weight among males was associated with decreased risk of depression and suicidal behavior. Similarly, Sullivan et al.32 found that the psychosocial consequences of obesity were greater in obese women (BMI ⬎ 34) than in obese men (BMI ⬎ 38). Psychopathology, in particular depression, is greater among obese persons who seek treatment than among those who do not.33 Any psychological burden of obesity is certainly exacerbated by our nation’s marked preoccupation with thinness. Cultural indicators of this obsession include the regular appearance of diet books on The New York Times’ Best Seller List, infomercials promising miracle weight-loss programs, and the proliferation of cosmetic surgery procedures to create a leaner appearance. This pursuit of thinness is fueled by two faulty assumptions. One is that weight is infinitely malleable and the other is that thinness is associated with happiness. Neither is true.34 It would be expected that an overweight person in a society preoccupied with thinness would suffer discrimination. Regrettably, there are plenty of examples. This discrimination is fueled by the visibility of obesity and the conviction that excess weight reflects a lack of personal control.35 The most disturbing studies about the stigma of overweight show that weight alone can elicit a host of negative attributes and characterizations. Children as young as 6 y label silhouettes of obese youngsters as “lazy, stupid, cheats, lies, and ugly.” Even more troublesome is that these judgments also are made by obese youngsters.36 A prospective study by Gortmaker et al.37 showed that, by their early 20s, women who had been obese in adolescence were poorer, less educated, and less likely to be married than were women who had been non-obese as teens. These findings were notable in that they persisted after controlling for baseline measures of intellectual ability, socioeconomic status, parental education, height, age, and ethnicity. In another study, college students were asked to rate different types of people for their suitability as marriage partners. Embezzlers, cocaine users, shoplifters, and blind persons were all rated as more suitable spouses then obese individuals.38 Discrimination is also found in the workplace.39 In studies of sales managers and supervisors, overweight employees were less likely to be assigned to challenging sales territories and more likely to be disciplined harshly than non-overweight employees, particularly for ethics violations.40,41 Sadly, health-care professionals share a negative view of the overweight.42 In a study of family physicians, 63% attributed obesity to a lack of will power and more than a third described their obese patients as lazy.43 It is not surprising that, when morbidly obese patients were asked to respond to the question of whether they had been treated disrespectfully by the medical profession based on their weight, 6% responded “never” and 46% responded “always.” In addition to these formal studies, there is an informal discrimination that is harder to measure. For example, in the current climate of political correctness, jokes about overweight persons are still fair game for sure laughs by comedians. Television situation
Nutrition Volume 16, Number 10, 2000 comedies regularly reinforce erroneous stereotypes of the obese as sloppy, lazy, gluttonous, and unable to perform or enjoy sex. Despite the fact that 55% of the population is overweight or obese,44 airplane seats, fashionable clothing, booths in restaurants, and classroom desks are constant reminders that obese persons are not taken seriously. One-size-fits-all examination gowns, scales that have 300- to 350-lb limits, and the use of inappropriately small blood pressure cuffs are similar examples in the medical environment.42 The effects of obesity on psychosocial aspects of quality of life have been most frequently assessed by three scales of the SF-36 (social functioning, emotional role, and mental health). A treatment-seeking sample of 312 obese subjects scored significantly lower than U.S. norms on the three scales, but the effect sizes were relatively small (⫺0.16 to ⫺0.28).12 Social functioning deteriorated from mild to moderate in morbidly obese subjects, whereas emotional role and mental health showed no effects of degree of overweight. When these 312 treatment seekers were compared with obese persons not seeking treatment, there were no differences across the three scales.45 Le Pen et al. found no differences on the three SF-36 scales among non-obese (n ⫽ 562), overweight (n ⫽ 236, BMI ⫽ 27–29.9), and obese (n ⫽ 155, BMI ⱖ 30) subjects. In a sample of 8561 subjects, Doll et al.23 reported that overweight (BMI ⫽ 25–29.9) subjects were comparable to normal-weight subjects. Those with moderate (BMI ⫽ 30 –39.9) and morbid (BMI ⱖ 40) obesity, however, scored lower and similar to the underweight (BMI ⬍ 18.5) subjects. Using an obesity-specific measure (Table I), Le Pen et al.1 found that obese subjects scored lower than non-obese subjects on a measure of “psychological state” but no different on a scale of “relations with other people.” Mathias et al.10 reported that obese patients scored worse on ratings of overweight distress, physical appearance, and the health-state preference (Table I). Sullivan et al.32 found that psychosocial functioning was worse in severely obese subjects when compared with healthy reference subjects and that nearly 20% of obese subjects had clinically significant scores on anxiety and approximately 10% for depression. Strikingly, obese subjects showed psychosocial functioning more similar to that of cancer survivors with a recurrence and worse functioning than to that of cancer survivors without recurrence or spinal cord injury patients after 4 y.
EFFECTS OF WEIGHT LOSS ON QUALITY-OF-LIFE MEASUREMENTS Given the significant adverse consequences of obesity and their effect on quality of life, it is imperative to assess whether weight loss improves the quality of life for obese patients.46 Numerous studies have assessed quality of life before and after weight loss, but fewer have included no or minimal weight-loss controls. The studies reviewed in this article assessed quality of life before and after weight loss and included appropriate controls.47–52 Several studies have assessed the effects of modest weight loss on quality of life. In a 12-wk study, 30 subjects who lost 6.1 ⫾ 4.0 kg experienced significantly greater improvements than did 14 control subjects who gained 1.3 ⫾ 1.3 kg on three of the eight subscales of the SF-36 (physical function, physical role, and mental health).49 Rossner et al.50 reported significantly greater improvements in quality of life in patients treated with 120 mg of orlistat (7.6% weight loss) than in placebo patients (4.5% weight loss) at 2 y in overweight distress, although no actual values were reported. In contrast, Mathias et al.10 found no differences among those who lost weight (⬎5%), gained weight (⬎5%) or were weight stable (⫾5%) on five of seven measures assessing quality of life, including the health-status preference and measures of general health, depression, self-esteem, and physical appearance. Overweight distress was greater in the weight-loss than in the
Nutrition Volume 16, Number 10, 2000 weight-stable subjects, and comparative health was highest in the weight-loss group and lowest in the weight-gain group. Four studies have assessed quality-of-life outcomes after surgical treatment for obesity.47,48,51,52 Karlsson et al.47 studied 487 surgical patients who lost approximately 30 kg and matched controls who lost 1 kg over 2 y and found significantly greater improvements in the surgical patients on an obesity-related psychosocial problems (OP) scale that measures the effects of obesity on everyday life measures of mood, the social introversion scale of the Sickness Impact Profile, and a general health-rating index. Using a similar sample of surgical and control patients, Narbro et al.48 showed that sick leave and disability were actually higher in surgical patients in the first year after treatment, significantly lower in years 2 and 3, and lower, but not significantly so, in year 4. Additional analyses showed that the difference between groups was largely accounted for by older subjects (⬎46.7 y) in a median split of the sample. In another surgical sample, Choban et al.51 assessed changes in SF-36 scores before and 18 mo after gastric bypass. At baseline, patients scored lower than national norms on all SF-36 scales except emotional role. After losing 63% of excess weight (approximately 40 kg), scores were comparable (physical role, physical functioning, mental health, and general health) or better (social functioning, bodily pain, and vitality) than national norms. Using the Nottingham Health Profile, van Gemmert et al.52 found similar improvements after surgery compared with control subjects, although the improvements decreased over 84 mo. These studies suggest that weight losses ranging from 6 kg49 to 30 kg47 result in significant improvements in the quality of life when compared with control subjects. The available literature is compromised by predominantly surgical samples that limit the ability to assess the effects of more typical (10%) weight losses. The most significant limitation of the current literature is the inability to assess clinical significance. It is important to know whether statistically significant changes reflect improvements within a normal range or movement from clinical to subclinical classification.53 The study by Karlsson et al. is noteworthy for providing the range of scores for each assessment, thereby facilitating interpretation of the mean scores. When assessing changes in quality of life, it is critical to look beyond mean values to assess clinical significance. For example, Karlsson et al.47 reported significant changes in both anxiety and depression after weight loss, but both were within the normal range of 6.3 to 4.6 (depression) and 5.2 to 3.0 (anxiety) within a range of 0 to 21. However, when assessing only those with a clinically significant score (⬎10), they found that the number of patients with clinically significant anxiety decreased from 21% to 11% and those with clinically significant depression decreased from 9% to 4%. Mean values can obscure these important changes in clinical status. Whether weight loss affects quality of life is an important consideration in assessing the overall efficacy of obesity treatment. Future studies would be enhanced by assessing a variety of approaches to weight loss, using both general and obesity-specific measures of quality of life and conducting follow-up studies to assess the effects of weight regain on quality of life.
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