Addictive Behaviors, Vol. 24, No. 3, pp. 345–357, 1999 Copyright © 1999 Elsevier Science Ltd Printed in the USA. All rights reserved 0306-4603/99/$–see front matter
Pergamon
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QUALITY OF LIFE AND OVERWEIGHT: THE OBESITY RELATED WELL-BEING (ORWELL 97) QUESTIONNAIRE EDOARDO MANNUCCI, VALDO RICCA, ELISABETTA BARCIULLI, MILENA DI BERNARDO, ROSSANA TRAVAGLINI, PIER LUIGI CABRAS, and CARLO MARIA ROTELLA University of Florence
Abstract — The development and validation of a self-reported measure of obesity-related quality of life, the Obesity Related Well-Being (ORWELL 97), were undertaken to examine the intensity and the subjective relevance of physical and psychosocial distress. The questionnaire was validated in a sample of 147 obese patients (99 females, 48 males). The Eating Disorder Examination 12.0D interview, a structured diagnostic interview for DSM-III-R (DSMIV criteria for binge eating disorder), Beck Depression Inventory, Binge Eating Scale, and the State-Trait Anxiety Inventory 1 and 2 scales were also applied. Internal consistency and testretest reliability were satisfactory. Factor analysis allowed the identification of two subscales: ORWELL 97-1 related to psychological status and social adjustment, and ORWELL 97-2 related to physical symptoms impairment. Obese female patients showed a lower quality of life, and the severity of obesity appeared to interfere with physical functioning rather than psychological status and social adjustment. The ORWELL 97 questionnaire appears to be a simple and reliable measure of obesity-related quality of life, which can be used in current clinical practice. © 1999 Elsevier Science Ltd
The long-term goal of treatment of a chronic disease, such as obesity, is the improvement of patients’ duration and quality of life. Patients’ quality of life, together with weight reduction and weight loss manteinance, should be considered among parameters of efficacy in treatment outcome studies. An accurate measure of obesity-related quality of life is therefore relevant for the evaluation of therapeutic interventions, not only in research but also in current clinical activity. Quality of life is the individual’s overall satisfaction with his or her life, and it expresses a relative value for the individual, related to his or her need and expectations (French, Rogers, & Cobb, 1974). Quality of life has been defined as “the satisfaction of an individual’s values, goals, and needs through the actualisation of their abilities or life-style” (Emerson, 1985). Assessment of quality of life involves the evaluation of several domains, including physical, psychological, and social well-being (Felce & Perry, 1995; Sullivan, Sullivan, & Kral, 1987). The negative impact of obesity on physical well-being and on psychosocial functioning has been well established (Fontaine, Cheskin, & Barofsky, 1996; Perri, Nezu, & Viegener, 1992; Stewart & Brook, 1983; Sullivan et al., 1993; Wadden & Stunkard, 1985). In affluent societies, obese persons are exposed to prejudice and discrimination: Stigmatization of obese individuals has been documented in most areas of social functioning (Maddox, Back, & Liederman, 1968; Sobal & Stunkard, 1989). Psychological distress related to obesity can be determined by subjects’ adherence to others’ negative judgment, as well as by the failure of attempts at the realization of the socially accepted standard of leanness (Ross, 1994). The impact of the impairment of physical Requests for reprints should be sent to Carlo Maria Rotella, Department of Pathophysiology, Endocrinological Unit, Section of Metabolic Diseases and Diabetology, University of Florence, Viale Pieraccini 6, 50134 Firenze, Italy; E-mail:
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well-being and functioning, which can be determined by being severely overweight, should be considered as a factor interfering with the patient’s psychological status. Impairment of quality of life in obese persons is therefore determined by several different physical, psychological, and social factors (Sarlio-Lähteenkorva, Stunkard, & Rissanen, 1995). Health-related quality of life refers to the overall effects of medical conditions on physical and mental functioning and well-being, as subjectively evaluated and reported by the patient. Health-related quality of life can be evaluated either through generic or disease-specific questionnaires. Most generic measures of quality of life (Bergner, Bobbit, & Carter, 1981; Hunt, Mc Kehna, & Mc Even, 1981; Parkerson, Genlbachs, & Wagner, 1981) are too complex to be applied in routine medical practice, and they are less sensitive to changes induced by therapy when compared to disease-specific measures (Guyatt, Bombardier, & Tugwell, 1986; Jacobson, Samson, & De Groot, 1994). Among the studies dealing with the quality of life of obese persons, the Swedish obese subjects intervention study (Sullivan et al., 1993) showed differences between obese and nonobese individuals on current health, psychological tests, and measures of psychiatric disability. Interestingly, the number of dieting attempts, body image perception, and amount of physical activity during leisure time provided independent contributions to explain the psychosocial status of the severely obese. The study of Fontaine et al. (1996), using the Medical Outcome Study Short-Form Health Survey (Ware, Snow, & Kosinski, 1993) to assess health-related quality of life, showed that obese people seeking weight-loss treatment reported substantial decreases in all eight domains with major complaints about bodily pain. Several studies report a relevant improvement of quality of life in obese patients after weight loss (Hafner, Watts, & Rogers, 1991; Kral, Sjöström, & Sullivan, 1992; Rabner & Greenstein, 1991; Rand & Macgregor, 1994; Stunkard, Stinnet, & Smoller, 1986). Kolotkin and collegues proposed an obesity-specific questionnaire of quality of life—the Impact of Weight on Quality of Life (IWQOL; Kolotkin, Head, Hamilton, & Tse, 1995). The questionnaire includes 74 items assessing the effects of weight on various areas of life. In preliminary validation studies, the IWQOL questionnaire shows some interesting features, but its psychometric properties need to be further assessed. It should be considered that the length of the questionnaire could make its use problematic in wide populations of patients. Moreover, the IWQOL, like most other measures of quality of life, considers all individual psychological symptoms equally relevant in the determination of the patients’ well-being. Conversely, clinical experience shows that symptoms of similar intensity can have a different impact on quality of life of individual patients, depending on the person’s values, beliefs, needs, and expectations. Therefore, the rating of symptoms should consider not only their intensity but also their subjective relevance. The aim of this study is to develop and validate a new self-reported measure of obesity-related quality of life, the Obesity Related Well-Being (ORWELL 97) questionnaire, that takes into consideration not only the intensity but also the subjective relevance of physical and psychosocial distress. M E T H O D
Development of the questionnaire The questionnaire has been developed with the contributions of several psychiatrists, endocrinologists, nurses, and dietitians who were asked to describe the most fre-
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quent and relevant complaints of obese patients recorded in daily clinical practice. A group of obese patients was asked to describe the effects of being overweight in their everyday life and to indicate the most distressing physical and psychological symptoms. On the basis of the most commonly voiced concerns, the authors identified 18 items. After an initial field testing on a small number of patients, the items were modified considering feedback from patients and other physicians. Patients involved in the developement of the ORWELL 97 were not used as subjects in the study reported herein. The items were conceptually related to three different areas: 1. Symptoms (five items) was intended to measure obesity-related somatic symptoms and physical functioning. The items of this subscale evaluate the symptoms and impairments of physical functioning that are most common in obese patients without concurring physical illnesses. 2. Discomfort (seven items) was aimed at the evaluation of the impact of obesity on patients’ emotional status and obesity-related worries. This scale is not a general psychopathology index, and therefore it is not designed to detect symptoms related to anxiety, mood, and eating disorders, which are frequently found in obese patients. 3. Impact (six items) was designed to measure the effects of obesity on familial relationship, role functioning, and social network. The items were developed in such a way that they could be applied to a wide population of obese patients, regardless of age, sex, familial status, occupation, or education level. The complete text of the questionnaire, together with the scoring system, is reported in the Appendix. For each item, the patient is asked to score on a 4-point Likert scale the occurrence and/or severity of the symptom (occurrence) and the subjective relevance of the symptom-related impairment in one’s own life (relevance). The score of the item is calculated as the product of occurrence and relevance. The total ORWELL 97 score is obtained as the sum of the scores of individual items. Higher ORWELL 97 scores mean a lower quality of life. The sums of the scores related to occurrence (ORWELL 97-O) and relevance (ORWELL 97-R) of symptoms in individual items were also calculated.
Patients The Italian translation of the questionnaire (which is available, upon request, from the authors) was evaluated in a consecutive series of obese (body mass index [BMI] . 30 kg/m2) patients attending the Outpatient Clinic of the Section of Metabolic Diseases and Diabetology at the University of Florence between February 1, 1997, and June 30, 1997. Those patients showing mental retardation and/or inability to read were excluded, as well as those affected by uncompensated clinical hypothyroidism, severe cardiovascular or respiratory diseases, and renal or hepatic failure. All patients underwent an oral glucose tolerance test to exclude diabetes mellitus, according to WHO 1985 criteria. All patients provided their informed consent prior to being enrolled in the study. For patients under 18 years of age, informed consent was provided by the legal guardians. Of the 159 patients who were asked to participate, 12 patients (7.5%; 8 females, 4 males) refused their consent, so the final sample included 147 patients (99 females, 48
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males) aged (M 6 SD) 45.2 6 13.4 years (range 5 15–73), with a BMI of 37.9 6 6.3 (range 5 30–61.3). All patients were examined by a psychiatrist using a structured diagnostic interview for mental disorder (Spitzer, Williams, Gibbon, & First, 1990). DSM-IV criteria (American Psychiatric Association, 1994) were used for the diagnosis of binge eating disorder. Of the 147 obese patients 51 were not affected by any mental disorder, 37 were currently affected by dysthymic disorder, 26 by generalized anxiety disorder, 7 by panic attack disorder, 6 by major depressive disorder, 6 by adaptation disorder with depressed mood, 2 by simple phobic disorder, 1 by alchol abuse, and 11 (7.5%) by binge eating disorder. Validation of the questionnaire Test-retest reliability. All patients were asked to complete the questionnaire twice, within 7 days. No specific treatment for obesity was administered between the two tests. Pearson’s correlations were then calculated between the scores of the total questionnaire and of individual items that were obtained each time. Four patients failed to complete the questionnaire for the second time; therefore, test-retest reliability was evaluated on a sample of 143 patients. Internal consistency. Internal consistency was evaluated using Cronbach’s alpha method (Cronbach, 1970). Clinical correlates. To evaluate the relationship between ORWELL 97 scores and clinical parameters, Pearson’s correlations were calculated; for correlation of ORWELL 97 scores with parameters that did not show a normal distribution, such as BMI, Spearman’s method was used. A two-tailed Student’s unpaired t test was applied for comparison of means. Multiple linear regression was applied to total ORWELL 97, ORWELL 97-R, and ORWELL 97-O scores using SPSS 5.0.2 for Windows 3.1, considering age, sex, and BMI as putative determinants of quality of life. Concurrent validity. Beside the ORWELL 97 questionnaire, the patients were also asked to complete the Beck Depression Inventory (BDI; Beck, 1978); anxiety was measured using the State-Trait Anxiety Inventory (STAI; Spielberg, Gorsuch, & Lushene, 1970); STAI-1 and STAI-2 measure state and trait anxiety, respectively. Eating attitudes and behavior were evaluated with validated Italian translations (Di Bernardo et al., in press; Mannucci, Ricca, Di Bernardo, & Rotella, 1996) of the Binge Eating Scale (BES) self-reported questionnaire (Gormally, Black, Daston, & Rardin, 1982) and the Eating Disorder Examination (EDE) 12.0D structured interview (Fairburn & Cooper, 1993). The EDE interview was administered by one of the authors (M.D.B.), who had previously received specific training at Warnerford Hospital, Oxford University. EDE provides (besides scores of eating disorder psychopathology) categorical diagnoses of eating disorders, following DSM-IV categories but with slightly different criteria. In the present sample, no differences were observed between DSM-IV and EDE diagnoses of binge eating disorder. Pearson’s correlations, were calculated among the ORWELL 97 total, ORWELL 97-O, and ORWELL 97-R scores and the scores obtained by the patients on each of the psychometric measures. Multiple linear regression was used to assess the individ-
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Table 1. Scores of individual items Item no.
M 6 SD
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
3.1 6 2.7 2.4 6 2.9 1.9 6 2.4 2.2 6 2.5 2.6 6 2.9 3.2 6 2.8 3.1 6 3.1 2.0 6 2.6 2.1 6 2.8 3.0 6 3.0 3.6 6 3.0 2.6 6 2.8 2.1 6 2.6 2.5 6 2.6 3.2 6 3.0 3.3 6 3.0 1.4 6 2.2 3.8 6 3.6
ual contribution of STAI, BDI, BES, and EDE to the variance of ORWELL 97 scores adjusted for age, sex, and BMI. Factor analysis. To verify the distribution of items into subscales, factor analysis was performed, using SPSS 5.0.2 for Windows 3.1. With factor analysis, the main factor contributing to variance of scores can be identified, and individual items can be assigned to subscales according to their factor loading. Clinical correlates and concurrent validity of subscales derived from factor analysis were evaluated following the procedures just described. R E S U L T S
Scores of individual items are summarized in Table 1. Mean ORWELL 97 total score was 47.9 6 27.0; mean ORWELL 97-O score was 27.9 6 9.5, and mean ORWELL 97-R was 28.7 6 8.1. Test-retest reliability A highly significant correlation between test and retest scores was observed for ORWELL 97 total score (r 5 .92, p , .01). Values of r obtained for each individual item ranged between .85 (Item 15: feeling nervous) and .96 (Item 4: feeling sleepy). Internal consistency Cronbach’s alpha for ORWELL 97 total score was .83. A value of a . .80 is considered satisfactory for internal consistency. Clinical correlates Obese females showed significantly higher mean ORWELL 97 total scores (meaning lower quality of life) when compared to males (54.2 6 26.5 vs. 35.0 6 24.3, respectively; p , .01). No significant correlation of age with ORWELL 97 total scores, OR-
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Fig. 1. Mean (6SD) ORWELL 97 total scores in patiens without (empty bar) and with (hatched bar) mental disorder. *p , .01.
WELL 97-O, and ORWELL 97-R was observed. BMI was found to correlate significantly (r 5 .22, p , .05, with Spearman’s method) to ORWELL 97-O but not to ORWELL 97-R or ORWELL 97 total scores. With multiple linear regression (using sex, BMI, and age as putative determinants of quality of life), a significant correlation of ORWELL 97 total scores was observed with sex (p , .01) but not with age or BMI. ORWELL 97-O was found to be significantly higher (p , .01) in females than in males, after adjustment of BMI and age (data not shown). The correlation between ORWELL 97-O and BMI was confirmed at multiple linear regression (adjusted r 5 .18, p , .05). Finally, ORWELL 97-R was significantly higher (p , .01) in females than in males, but no correlation was found with age and BMI (data not shown). Patients with mental disorder showed significantly (p , .01) lower ORWELL 97 scores when compared with those who were not affected by mental disorders (Figure 1). Concurrent validity Correlations between ORWELL 97 scores and other psychometric measures are summarized in Table 2. ORWELL 97 total scores, ORWELL 97-O, and ORWELL 97-R showed a significant positive correlation with BDI, BES, STAI-1, and STAI-2 scores but not with EDE total or subscale scores. Using multiple linear regression (considering age, sex, and BMI among putative determinants of quality of life) a correlation of BES with ORWELL 97 total score (adjusted r 5 .28, p , .05) and ORWELL 97-O (adjusted r 5 .37, p , .01) was confirmed but not with ORWELL 97-R. BDI was found to correlate significantly with ORWELL 97 total score (adjusted r 5
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Table 2. Pearson’s correlations between ORWELL scores and other psychometric measures
ORWELL 97 Total ORWELL 97-O ORWELL 97-R
BDI
BES
EDE 1
EDE 2
EDE 3
EDE 4
EDE Total
STAI-1
STAI-2
.60** .48* .46**
.58** .55** .43**
2.08 .13 .07
2.03 2.02 2.10
2.14 2.09 .04
2.09 .03 .05
2.13 2.01 .03
.56** .45** .53**
.58** .47** .55**
Note. BDI = Beck Depression Inventory; BES = Binge Eating Scale; EDE = Eating Disorder Examination; STAI = State-Trait Anxiety Inventory; O = occurrence; R = relevance. *p , .01; **p , .001.
.31, p , .05) but not with ORWELL 97-O and ORWELL 97-R. No correlation of STAI-1 and STAI-2 was confirmed at multiple linear regression. Factor analysis With factor analysis, two main factors (eigenvalue . 1.5) were identified, which accounted for 40.8% of total variance. Factor 1 accounted for 30.3% of variance, and Factor 2 accounted for 10.4%. Individual items were assigned to two different subscales, related to Factors 1 and 2, based on their factor loading (Table 3). The ORWELL 97-1 subscale contained items related to psychosocial aspects, and the ORWELL 97-2 subscale included items that investigated physical discomfort related to obesity. No significant differences in ORWELL 97-2 scores were observed between males and females; however, obese females showed significantly (p , .01) higher ORWELL 97-1 scores when compared to males (Figure 2). ORWELL 97-1 and ORWELL 97-2 did not show any significant correlation with age. ORWELL 97-2 showed a significant correlation with BMI (r 5 .24, p , .05), but ORWELL 97-1 did not. ORWELL 97-1 showed a significant positive correlation with BDI (r 5 .60, p , .01), BES (r 5 .57, p , .01), STAI-1 (r 5 .41, p , .01), and STAI-2 (r 5 .45, p , .01) but not with EDE total or subscale scores. ORWELL 97-2 showed a significant positive correlation with BDI (r 5 .40, p , .01), BES (r 5 .37, p , .01),
Table 3. Factor analysis of ORWELL 97 factor-analysis-derived subscales and factor loadings for individual items Item 15. Feeling nervous 10. Showing one’s body 12. Derision 14. Sadness 11. Sexual attractiveness 13. Apprehension 8. Work 9. Social activities 16. Self-esteem 17. Feeling in danger 7. Familial relationship 6. Health concern 18. Social model 2. Sexual life 3. Short breath 4. Feeling sleepy 5. Sweating 1. Physical activity
ORWELL 97-1 (Factor 1)
ORWELL 97-2 (Factor 2)
.71 .70 .68 .65 .64 .64 .63 .61 .61 .60 .43 .31 .26 .56 .54 .54 .48 .45
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Fig. 2. Mean (6SD) ORWELL 97 Factor 1 and ORWELL 97 Factor 2 scores in females (empty bars) and males (hatched bars).
STAI-1 (r 5 .24, p , .05), and STAI-2 (r 5 .30, p , .01) but not with EDE total or subscale scores. With multiple linear regression (considering sex, age, and BMI), ORWELL 97-1 correlated with BDI (adjusted r 5 .42, p . .01) and BES (adjusted r 5 .28, p , .05) but not with STAI-1 and STAI-2. ORWELL 97-2 correlated only with BES (adjusted r 5 .33, p , .05) and not with BDI, BMI, STAI-1, and STAI-2. D I S C U S S I O N
The ORWELL 97 questionnaire showed a satisfactory internal consistency and testretest reliability in a population of obese outpatients seeking treatment for being overweight. The application of factor analysis allowed the identification of two distinct subscales. The first, ORWELL 97-1, which contains 13 items, appears to be related to psychological status and social adjustment, and the second, ORWELL 97-2, which contains five items, is related to physical symptoms and impairment. Among obese patients, females showed significantly higher scores than males, meaning a lower quality of life. A similar difference between sexes has been observed for other disease-specific quality-of-life measures (DCCT Research Group, 1989;
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Mannucci, Ricca, Bardini, & Rotella, 1996), and it is consistent with literature about the impact of weight on quality of life (Kolotkin et al., 1995; Sullivan et al., 1993). It should be considered that psychiatric morbidity has been reported to be higher in females than in males. Several epidemiological studies (Dohrenwend & Dohrenwend, 1976; Sullivan et al., 1993; Tibblin, Bengtsson, Furunes, & Lapidus, 1990; Weissman & Klerman, 1977) have shown that women show a worse psychological status when compared to men. It could be speculated that females have a greater susceptibility to anxiety and depression as an aspecific reaction to a variety of different impairments. Among ORWELL 97 subscales, ORWELL 97-1 (but not ORWELL 97-2) scores were significantly higher in females when compared to males; the difference between sexes is entirely due to a greater impact of being overweight regarding psychosocial complaints in females. A previous study (Kolotkin et al., 1995) reported that women experience the effects of their weight more profoundly than do men in the areas of self-esteem and sexual life, and this finding is consistent with what is generally known about gender differences in body image (Striegel-Moore, McAvay, & Rodin, 1986). In fact, women experience a greater social and cultural drive for thinness than men do (Foster & Wadden, 1994). Age did not appear to affect ORWELL 97 scores. The ORWELL 97 questionnaire is therefore capable of exploring obesity-related quality of life in a wide age range. BMI correlated positively, at simple and multiple linear regression, with the occurrence of symptoms (ORWELL 97-O) but not with the relevance of symptoms (ORWELL 97-R). In fact, the severity of overweightness is clearly related to the occurrence and intensity of symptoms but not to their subjective relevance, which depends on each patient’s individual personality, beliefs, ideals, lifestyle, and cultural background. A positive linear correlation of BMI was found with ORWELL 97-2 (physical symptoms) but not with ORWELL 97-1 (psychosocial impact), suggesting that severity of obesity interferes with physical functioning rather than with psychosocial status and social adjustment. Patients with mental disorders showed higher ORWELL 97 scores. The impact of mental disorders on obesity-related quality of life is confirmed by the correlation of BDI and STAI scores (measuring depression and anxiety, respectively) with ORWELL 97 scores. BDI and STAI scores showed a significant correlation with both ORWELL 97-O and ORWELL 97-R, meaning that higher levels of depression and anxiety are associated with a greater occurrence of obesity-related symptoms and with an increased subjective relevance of impairment determined by being overweight. At multiple linear regression, when considering scores of all psychomethric instruments as putative determinants of quality of life, the correlation of ORWELL 97 with BDI was confirmed, whereas that with STAI was not. It should be noted that an increase in anxiety is often associated with depressive symptomatology, which can be a relevant symptom of mood disorders such as dysthymia or major depression. Depression appears to be a more relevant independent factor in terms of weight-related quality of life when compared to anxiety. Patients with binge eating disorder showed higher ORWELL 97 scores, meaning a lower quality of life. Scores on the BES, which measures binge eating behavior, appeared to affect ORWELL 97 scores upon multiple linear regression. This confirms that binge eating is associated with increased obesity-related distress. A positive correlation with BES scores was found with both ORWELL 97-1 and ORWELL 97-2. It should be noted that patients with binge eating disorder show a higher BMI (Marcus, 1995), leading to increased physical impairment; moreover, patients with binge eating
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disorder show higher levels of psychopathology (Marcus, 1995; Ricca et al., 1998), which could interfere with quality of life. No correlations were found between ORWELL 97 and EDE scores. It should be made clear, however, that EDE explores a domain (e.g., eating attitudes) that is clearly distinct from that of obesity-related quality of life. ORWELL 97, therefore, independently from eating attitudes, was shown to be a specific measure of physical and psychosocial impairment determined by being overweight. In conclusion, the ORWELL 97 questionnaire appears to be a simple and reliable measure of obesity-related quality of life, which can be used with obese people seeking treatment for being overweight. Considering its simple administration, the questionnaire could be a valuable instrument in current clinical practice. R E F E R E N C E S American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Beck, A. T. (1978). Beck Depression Inventory. Philadelphia: Center for Cognitive Therapy. Bergner, M., Bobbit, R. E., & Carter, W. B. (1981). The Sickness Impact Profile: Development and final revision of a health status measure. Medical Care, 19, 787–798. Cronbach, L. J. (1970). Essentials of psychological testing (3rd ed.). New York: Harper & Row. DCCT Research Group. (1989). Reliability and Validity of a Diabetes Quality of Life (DQOL) measure for the Diabetes Control and Complication Trial (DCCT). Diabetes Care, 11, 725–731. Di Bernardo, M., Barciulli, E., Ricca, V., Mannucci, E., Cabras, P. L., & Rotella, C. M. (in press). Validazione della traduzione italiana della Binge Eating Scale. Minerva Psichiatrica. Dohrenwend, B. P., & Dohrenwend, B. S. (1976). Sex differences and psychiatric disorders. American Journal of Sociology, 81, 1447–1454. Emerson, E. B. (1985). Evaluating the impact of deinstitutionalization on the lives of mentally retarded people. American Journal of Mental Deficiency, 88, 345–351. Fairburn, C. G., & Cooper, Z. (1993). The Eating Disorder Examination. In C. G. Fairburn & G. T. Wilson (Eds.), Binge Eating: Nature, assessment and treatment (12th ed., pp. 317–348). New York: Guilford. Felce, D., & Perry, J. (1995). Quality of life: Its definition and measurement. Research in Developmental Disability, 16, 51–74. Fontaine, K. R., Cheskin, L. J., & Barofsky, I. (1996). Health-related quality of life in obese persons seeking treatment. The Journal of Family Practice, 43, 265–270. Foster, G. D., & Wadden, T. A. (1994). The psychology of obesity, weight loss, and weight regain: Reaserch and clinical finding. In G. L. Blackburn & B. S. Kanders (Eds.), Obesity: Pathophysiology, psychology and treatment (pp. 140–159). New York: Chapman and Hall. French, J. R. P., Rogers, W., & Cobb, S. (1974). Adjustment as person-environment fit. In G. V. Coelho, D. A. Hamburg, & J. E. Adams (Eds.), Coping and adaptation (pp. 316–333). New York: Basic Books. Gormally, J., Black, S., Daston, S., & Rardin, D. (1982). The assessment of binge eating severity among obese persons. Addictive Behaviors, 7, 47–55. Guyatt, G., Bombardier, C., & Tugwell, P. (1986). Measuring disease specific quality of life in clinical trials. Canadian Medical Association Journal, 134, 889–896. Hafner, R. J., Watts, J. M., & Rogers, J. (1991). quality of life after gastric bypass for morbid obesity. International Journal of Obesity, 15, 555–560. Hunt, S. M., Mc Kehna, S. P., & Mc Even, J. (1981). The Nottingham Health Profile: Subjective health status and well being of patients with chronic conditions: Results from the Medical Outcome Study. Journal of the American Medical Association, 262, 907–913. Jacobson, A. M., Samson, J. A., & De Groot, M. (1994). The evaluation of two measures of quality of life in patients with type I and type II diabetes. Diabetes Care, 17, 267–274. Kolotkin, R. L., Head, S., Hamilton, M., & Tse, C. J. (1995). Assessing impact of weight on quality of life. Obesity Research, 3, 49–56. Kral, J. G., Sjöström, L. V., & Sullivan, M. B. E. (1992). Assessment of quality of life before and after surgery for severe obesity. American Journal of Clinical Nutrition, 55, 611S–614S. Maddox, G. L., Back, K. W., & Liederman, V. R. (1968). Overweight as social deviance and disability. Journal of Health and Social Behavior, 9, 287–298. Mannucci, E., Ricca, V., Bardini, G., & Rotella, C. M. (1996). Well-being enquiry for diabetics: A new measure of diabetes-related quality of life. Diabetes, Nutrition and Metabolism, 9, 89–102. Mannucci, E., Ricca, V., Di Bernardo, M., & Rotella, C. M. (1996). Studio del comportamento alimentare con una intervista strutturata: La Eating Disorder Examination. Il Diabete, 8, 127–131.
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R refers to “relevance” and O to “occurrence” on the ORWELL 97 questionnaire. 1. R: How important is it for you to exercise regularly? (0, not at all; 1, just a little; 2, not so much; 3, much) O: Is your weight an obstacle for your physical activity? (0, not at all; 1, just a little; 2, not so much; 3, much) 2. R: How important is it for you to have regular sexual activity? (0, not at all; 1, just a little; 2, not so much; 3, much) O: Does your weight represent a physical obstacle for your sexual activity? (0, not at all; 1, just a little; 2, not so much; 3, much) 3. O: Do you suffer from shortness of breath? (0, not at all; 1, just a little; 2, not so much; 3, much) R: Does shortness of breath represent an obstacle for your daily activities? (0, not at all; 1, just a little; 2, not so much; 3, much) 4. O: Do you ever feel sleepy? (0, never; 1, occasionally; 2, sometimes; 3, often)
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R: Does sleepiness interfere with your daily activities? (0, not at all; 1, just a little; 2, not so much; 3, much) O: Do you suffer from excessive sweating? (0, not at all; 1, just a little; 2, not so much; 3, much) R: Does sweating interfere with your daily activities? (0, not at all; 1, just a little; 2, not so much; 3, much) O: Mass media (TV, newspapers, etc.) often report that obesity is a major risk for health. Do you pay attention to this subject? (0, not at all; 1, just a little; 2, not so much; 3, much) R: Does this information increase your preoccupation with your health? (0, not at all; 1, just a little; 2, not so much; 3, much) R: Is it important for you to live in a serene family environment? (0, not at all; 1, just a little; 2, not so much; 3, much) O: Does being overweight prompt discussions in your family? (0, not at all; 1, just a little; 2, not so much; 3, much) R: Is it important for you to be successful in your job? (0, not at all; 1, just a little; 2, not so much; 3, much) O: Does your weight represent an obstacle in your job? (0, not at all; 1, just a little; 2, not so much; 3, much) R: Is it important for you to spend your free time with friends? (0, not at all; 1, just a little; 2, not so much; 3, much) O: Does your weight interfere with your social activities? (0, not at all; 1, just a little; 2, not so much; 3, much) O: Do you feel uneasy in showing your body? (0, not at all; 1, just a little; 2, not so much; 3, much) R: Does this uneasiness interfere with your leisure activities? (0, not at all; 1, just a little; 2, not so much; 3, much) O: Is it important for you to be sexually attractive? (0, not at all; 1, just a little; 2, not so much; 3, much) R: Does being overweight make you less sexually attractive? (0, not at all; 1, just a little; 2, not so much; 3, much) O: Do others ever tease you about your weight? (0, never; 1, occasionally; 2, sometimes; 3, often) R: If this happens, does it worsen your mood? (0, not at all; 1, just a little; 2, not so much; 3, much) R: Do you feel excessively worried about uninmportant matters? (0, not at all; 1, just a little; 2, not so much; 3, much) O: Do you think that being overweight makes you more apprehensive? (0, not at all; 1, just a little; 2, not so much; 3, much) R: Do you ever feel sad? (0, not at all; 1, just a little; 2, not so much; 3, much) O: Do you ever feel sad because of being overweight? (0, not at all; 1, just a little; 2, not so much; 3, much) R: Do you ever feel very nervous? (0, not at all; 1, just a little; 2, not so much; 3, much) O: Does being overweight make you more nervous? (0, not at all; 1, just a little; 2, not so much; 3, much) R: Do you have a negative opinion of yourself? (0, not at all; 1, just a little; 2, not so much; 3, much)
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O: Does being overweight interfere with your opinion of yourself? (0, not at all; 1, just a little; 2, not so much; 3, much) 17. R: Do you ever experience a feeling of immediate danger with no apparent reason? (0, not at all; 1, just a little; 2, not so much; 3, much) O: Do you feel more exposed to risks because of being overweight? (0, not at all; 1, just a little; 2, not so much; 3, much) 18. O: The world of fashion and entertainment pursues a model of lean persons. How far do you feel from this model? (0, not at all; 1, just a little; 2, not so much; 3, much) R: Would it be important for you to reach this model of thinness? (0, not at all; 1, just a little; 2, not so much; 3, much)