Volume 4: No. 3, July 2007
Quality of Life for Obese Women and Men in Turkey
Fulden Saraç, MD, Sebnem Parýldar, MD, Erdal Duman, MD, Fusun Saygýlý, MD, Mehmet Tüzün, MD, Candeger Yýlmaz, MD
Suggested citation for this article: Saraç F, Parýldar S, Duman E, Saygýlý F, Tüzün M, Yýlmaz C. Quality of life for obese women and men in Turkey. Prev Chronic Dis [serial online] 2007 Jul [date cited].
Available from: http://www.cdc.gov/pcd/issues/2007/
Obesity is a complex, multifaceted disease that is widespread and growing in the
developing world. People who are obese experience health-related quality-of-life
We administered the SF-36 Health Survey questionnaire to 1752 obese adults and
400 normal-weight adults in Izmir City, Turkey. We then compared the mean
scores of the two groups by sex in eight quality-of-life domains.
Differences in scores between obese women and normal-weight women were statistically significant in seven of eight SF-36 domains; differences in
scores between obese men and normal-weight men were statistically
significant in six of eight domains. Obese women were significantly more
impaired than obese men in four of eight domains. Among obese women, 45.0%
experienced a reduced quality of life, compared with only 13.2% of normal-weight
women. Similarly, 41.3% of obese men experienced a reduced quality of life,
compared with only 9.3% of normal-weight men.
Obesity is associated with poor levels of health, particularly poor levels of physical and social well-being.
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Obesity is a complex, multifaceted disease that is widespread and growing in the developing world. People who are obese experience health-related quality-of-life impairments. Impairment in an obese individual’s capacity to live as fully and actively as he or she desires may be as serious a consequence of obesity as its adverse effects on morbidity and mortality
(1). Both physical and psychosocial functioning have been shown to be negatively affected by excess weight; greater
impairments have been associated with greater degrees of obesity (2).
In 1947, the World Health Organization defined health as both the
absence of disease and infirmity and the presence of physical, mental, and
social well-being (3). Health-related quality of life refers to well-being in
the physical, psychological, and social domains; well-being in each domain can
be assessed by measuring an individual’s objective functioning and subjective
perceptions of health. Quality-of-life assessments can be used to measure and
compare the effectiveness of different treatments and to evaluate the impact of
a treatment on how patients feel and function in their everyday lives (4).
Until recently, there has been little standardization of quality-of-life measures among people who are obese; many researchers have simply developed their own set of nonvalidated questions. The field of quality-of-life research has grown, however, and standards for developing and validating quality-of-life instruments have been proposed (4-11). The SF-36 Health Survey (QualityMetric Inc,
Lincoln, RI) has been used to study obesity because it is comprehensive, brief,
psychometrically sound, and consistent with current guidelines for health-related quality-of-life instruments (4,11-15).
Our aim in this study was to compare the health-related quality of life of
obese and normal-weight adults in Turkey. In addition, we sought to describe the conditions contributing to
poor health-related quality of life among obese patients. We hypothesized that obesity negatively affects both physical and psychosocial functioning.
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The study population consisted of two groups of adults aged 20 to 65: an
obese group of 1752 (254 men and 1498 women) and a normal-weight group of 400
(150 men and 250 women). The obese participants were all patients at an obesity
clinic operated by the Department of Endocrinology and Metabolism at Ege
University in Izmir City, Turkey; patients with associated comorbidities such as
hypertension, diabetes mellitus, or cardiovascular disease were excluded from
the study. The group of normal-weight men and women were recruited from the general outpatient population of the Department of Endocrinology and Metabolism at Ege University.
Diagnosis of obesity was determined by measurement of body mass index (BMI
[weight in kg/height in m2]). Those in the obese group had a BMI
greater than or equal to 30.0;
those in the normal-weight group had a BMI less than 25.0. All participants signed an informed consent form, and
the Ege University Hospital ethics committee approved the study.
To assess participants’ health-related quality of life, we used the Medical Outcomes Study Short Form-36 Health Survey (SF-36) developed by Ware et al (12).
We translated the questionnaire into the Turkish language. Responses were included in the analysis only if all domains of the questionnaire were
answered in full. The questionnaire took an average of 20 minutes to complete (range, 15–45 min). The
survey was conducted from November 2004 through December 2005.
The SF-36 questionnaire
The SF-36 questionnaire is a self-evaluation instrument consisting of 36 items,
including 35 items in eight domains that provide a scaled assessment of respondents’ quality of
life during the previous 4 weeks. Ten items address the domain
of physical functioning, defined as limitations in physical activities such as bathing or dressing because of health
problems; four items address the domain of role-physical limitations, defined as limitations in usual activities such as work or other daily activities because of physical health problems; two items
address the domain of bodily pain; five items address the domain of general health; four items
address the domain of vitality (energy and fatigue); two items address the
domain of social functioning, defined as limitations in social activities because of physical or
emotional problems; three items address the domain of role-emotional limitations, defined as limitations in usual activities such as work or other daily activities because of emotional problems; and five items
address the domain of general mental health. The single unscaled item asks respondents about
their general health compared with 1 year ago.
SF-36 scoring rules and statistical analysis
Each of the 36 items was scored on a scale from 0 to 100, with 100
representing the most favorable state of health. We then summarized the scores
for each item and averaged the scores for items within each domain to produce
domain scores. All scoring was performed by a psychiatrist using the scoring
algorithm developed by Ware et al (12).
We used a two-tailed t test to compare domain scores of the obese and normal-weight groups and considered differences to be significant at α
= .05. In addition,
we defined a decrease in quality of life for an individual as an
average score of less than 50 for the eight SF-36 domains. We calculated the
percentage of individuals within each group who scored less than 50.
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All individuals surveyed completed the questionnaire in full. Table 1 shows the mean age
and BMI by sex for each participant group.
Table 2 shows the mean scores
by sex for obese participants and normal-weight participants in each of the eight SF-36 domains. Differences in scores between obese women and normal-weight women were statistically significant in seven of eight domains; the sole exception was for vitality. Differences in scores between obese men and normal-weight men were statistically
significant in six of eight domains; the two exceptions were for role-emotional and vitality.
We found that obese women were significantly more impaired
than obese men in four of eight domains: role–emotional (P =
.05), vitality (P = .03), bodily pain (P = .04), and general
health perception (P = .001).
Among obese women, 45.0% (674/1498) experienced a reduced quality of life, compared with only 13.2%
(33/250) of normal-weight women. Similarly, 41.3% (105/254) of obese men experienced a reduced quality of life, compared with 9.3%
(14/150) of normal-weight men.
Table 3 shows how each participant group responded to each SF-36 question.
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Obesity is a major public health problem associated with increased health risks (1,3,15-18).
The results of our study showed that obesity was related to role-emotional
limitations and physical problems. People with obesity uniformly perceive their general health as poorer than healthy-weight
people perceive their health (3,18,19). Moreover, a continuum has been observed
between mildly, moderately, and severely (morbidly) obese individuals and worsening perceived health status. Some studies found obesity to be associated with compromised quality of life and mental well-being (4,9,18,20,21).
Obese people have also been shown to have poorer psychological profiles than other
chronically ill people (16), and BMI levels have been found to be positively correlated with reports of self-harm
and psychiatric illness (17,22). Investigators also found that higher waist-to-hip ratios are associated with lower socioeconomic status, work problems, unemployment, and increased sedentary behavior
among men and women (4,23,24).
Fontaine et al administered the SF-36 questionnaire to 334 people seeking outpatient weight-loss treatment
and found that they scored significantly worse than population norms in eight domains;
they also found that a morbidly obese subgroup scored significantly worse in six of the eight scales (17). On the other hand, some studies found little difference between obese and nonobese
groups in their scores on standard psychological tests (23-25).
Obesity is no doubt, however, associated with some loss of quality of life, particularly in physical well-being (22,26-29). In a population sample of 3443 men and women from the Netherlands, Seidell et al found that BMI was
positively associated with the number of health complaints (20). Similarly, Richards et al compared the functional status of 345 sibling pairs,
one classified as severely obese (BMI ≥35.0) and the other classified as normal weight
(24). All SF-36 functional status and emotional well-being scores were significantly lower
among the severely obese participants than among their normal-weight siblings. Furthermore,
those who were severely obese perceived their general health to be poorer and more likely to get worse than did
their normal-weight siblings (24).
Body-image dissatisfaction (19) and binge-eating disorder (18,30) are
both more common among obese people than among normal-weight people (22).
Although few obese patients have clinically significant problems with body
image, binge-eating disorder is associated with high rates of psychopathology, particularly depression (25).
Some obese people 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. A recent study
suggested that gender may modify the psychological risk of obesity. In a general
population sample, excess weight among women was associated with an increased
risk for major depression, suicidal thoughts, and suicide attempts (11,28),
whereas excess weight among men was associated with a decreased risk for depression and suicidal behavior (28). Similarly, Sullivan et al found that the psychosocial consequences of obesity were greater
among women with a BMI greater than 34.0 than among men with a BMI greater than 38.0 (29).
Mathias et al reported that obese patients scored worse than normal-weight
individuals on ratings of overweight distress, physical appearance, and health-state preferences
(31). Doll et al found a strong inverse relationship between BMI and quality of life (32). In
our study, we found obesity to be associated with both poorer quality of life and
decreased mental well-being, compared with normal weight. For example, we found that 25.9% of obese women and
16.2% of obese men reported difficulty bathing or dressing themselves; only 7.8%
of normal-weight women and no normal-weight men found difficulty with this task. This finding shows that obesity affects physical well-being and
the ability to perform daily activities.
Evidence of a negative correlation between obesity and psychological quality of life
is equivocal, and it is much weaker than evidence
of a negative correlation between obesity and physical quality of life. Earlier
studies found few or no differences between obese and normal-weight people in psychological functioning (1,2). Similarly, recent population-based studies demonstrated
marked differences between obese and nonobese people in their physical quality of life but few differences
between them in their psychological or social quality of life. Nevertheless, there is some good evidence that obesity
does negatively affect psychological quality of life (4,32,33).
Studies of self-reported health status show that women are more likely than
men to report impaired health (28,30,31,33,34). Similarly, women
are more likely than men to report impaired body image or body satisfaction, and obese women
are more likely than obese men to report impaired health-related quality of life
(35). In our study, we found that obese women were
significantly more impaired than obese men in four of the eight quality-of-life
domains. The results of our study add to the substantial body of evidence that obesity is associated with poor levels of health status, particularly
with poor levels of physical and social well-being.
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Corresponding Author: Fulden Saraç, MD, Department of Endocrinology and Metabolism, 5th Floor, Ege
University Hospital, Bornova, Izmir, 35100 Turkey. Telephone: 90 (232) 373-7701. E-mail: firstname.lastname@example.org.
Author Affiliations: Sebnem Parýldar, Department of Psychiatry, Ege University, Izmir, Turkey; Erdal Duman, Fusun Saygýlý, Mehmet Tüzün, Candeger Yýlmaz, Department of Endocrinology and Metabolism, Ege
University Hospital, Izmir, Turkey.
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